Welcome to the SNI Forward, our quarterly snapshot of the transformation progress at California’s public health care systems and the work of the California Health Care Safety Net Institute (SNI).

As we step into 2020, we are reminded of our successes from the past year and the challenges and opportunities before us. Last year, SNI held true to its mission of supporting cross-member learning by hosting five in-person meetings for nearly 400 attendees and 66 webinars for over 2,400 participants on topics such as social needs screenings and data analytics for population health.

Public health care systems also completed year four of the PRIME program – an ambitious five year pay-for-performance initiative, which drives performance improvement and value-based care. On our recent PRIME webinar, Los Angeles County Department of Health Services and UC San Diego, shared their implementation experiences with a focus on how the program has impacted patient care.

At the CAPH/SNI Annual Conference this past December, we recognized the exceptional efforts of several members with the Quality Leaders Awards (QLA), which showcase innovative approaches to advance care and population health. The 2019 QLA winners focused on caring for complex patients, including those facing homelessness, behavioral health, and/or substance use, and addressing patients’ social needs.

With our signature waiver programs expiring at the end of this year, we are working hard alongside members to help inform the next iteration of Medi-Cal. Although there are always challenges inherent with change, we know that transition brings opportunity and we continue to support and accelerate the great work of public health care systems in California.

We hope you enjoy this edition of the SNI Forward.

Giovanna Giuliani
Executive Director
California Health Care Safety Net Institute

Program Highlight – WIT

During the annual conference, SNI hosted the tenth Waiver Integration Team+ (WIT+) Convening, bringing together over 100 clinical, operational, and data leaders to discuss how waiver programs will evolve after 2020, including through changes outlined in the Department of Health Care Services’ (DHCS) Medi-Cal Healthier California for All proposal (formerly CalAIM).

Participants assessed opportunities related to DHCS’ Population Health Management Program (PHMP), which ties together several of the Medi-Cal Healthier California for All proposals that impact public health care systems. Participants spoke with their teams and with other system leaders about how they are preparing for the changes ahead, including the roles and responsibilities of public health care systems and health plans under the PHMP transition. Other topics related to Medi-Cal Healthier California for All were discussed, including health and social needs assessments, data sharing, enhanced care management, in-lieu-of-services, and the Quality Incentive Program (QIP).

WIT+ attendees left the convening with a deeper understanding of Medi-Cal Healthier California for All and initial strategies to plan for the transition with health plan partners.

By the Numbers – PRIME

The Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program, now in its fifth and final year, continues to improve quality and health outcomes for patients. Based on data from program year four, CAPH/SNI members met 88% of their pay-for-performance (P4P) targets.

As shown, PRIME has made an impressive impact on the lives of patients in several key areas, such as blood pressure control, depression and tobacco screening, and collection of data on sexual orientation and gender identity, referred to as SOGI.

In December, over 100 attendees joined our PRIME webinar to learn more about year four performance trends. Two members, Los Angeles County Department of Health Services and UC San Diego, shared on the ground examples of patient impact across their systems.

To access the recording and slides, click here.

Member Profiles

Every year, at the CAPH/SNI Annual Conference, we present the Quality Leaders Awards (QLA) to highlight our members’ innovative approaches to providing high-value, high-quality, patient-centered care. Learn more about the outstanding 2019 winners below.

Top Honor – Santa Clara Valley Medical Center

To improve care for patients with complex needs, such as homelessness, substance use disorder, and mental illness, Santa Clara Valley Medical Center developed the Post-Acute Care Transitions (PACT) initiative to coordinate seamless transitions from the hospital to a nursing home, where patients can access medical and social services to facilitate their return to the community.

Performance Excellence – San Joaquin General Hospital

To better care for patients with heart failure and related hospital admissions, San Joaquin General Hospital redesigned their heart failure clinic to improve access, ensure supportive transitions of care, and address social needs.

Data-Driven Organization – Riverside University Health System

To address patients’ unidentified non-physical health needs, Riverside University Health System created the Whole Person Health Score, a comprehensive physical, emotional, and social health assessment to engage patients on what matters most to them.

Ambulatory Care Redesign – LAC+USC Medical Center

To address the opioid epidemic, LAC+USC Medical Center Adult Primary Care implemented a series of interventions, including improving patient-provider continuity, increasing visit frequency, and empowering pharmacy oversight, to safely reduce opioid prescribing for patients experiencing chronic, non-cancer pain

What’s Next

Highlights from SNI Programs in the Upcoming Quarter

  • Whole Person Care: The Essential Role of Community Health Workers & Peers – On February 13, CAPH/SNI will partner with the Camden Coalition of Healthcare Providers, the California Health Care Foundation, and county associations to host a workshop for Whole Person Care pilots to share promising practices for strengthening and sustaining the community health worker and peer workforce.
  • QIP Readiness Meeting – On April 2, SNI will convene PRIME and QIP leaders, program managers, and reporting analysts to share learnings from four years of PRIME and two years of QIP, and how members are preparing for the next iteration of QIP, which will include measures from both programs.