Welcome to the summer edition of the SNI Forward, our quarterly snapshot of the transformation efforts underway at California’s public health care systems, and the work of the California Health Care Safety Net Institute (SNI).
One of SNI’s roles is to share the accomplishments of public health care systems, not just to support the spread of innovative practices, but also to pause and recognize the leadership role that our systems play in advancing value-based care. We’re pleased to share that this June, eight CAPH members were selected to present at America’s Essential Hospitals’ (AEH) annual conference. They presented on topics such as addressing social determinants, value-based population health strategies, reducing disparities, hospital-based violence interventions, and Whole Person Care (WPC).
In this newsletter, we recap just a subset of the exciting work that SNI, our members, and their county partners shared at AEH’s conference, including promising outcomes of San Mateo County Health’s WPC pilot and system-level data demonstrating the advancements public health care systems have made in addressing disparities in care. We also feature a recent SNI meeting focused on efficient and patient-friendly strategies for managing multiple screening needs.
We are pleased to play a role in helping to share the expertise and best practices of public health care systems, not only among our members, but also nationally, because it’s essential that these stories continue to be shared as a model of transformation.
We hope you enjoy this edition of the SNI Forward.
Giovanna Giuliani
Executive Director
California Health Care Safety Net Institute
Member Collaboration
Better Screening for Improved Health Workshop
Screening patients for physical and behavioral health care needs, social needs, substance use, and lifestyle behaviors is key to providing high-quality and comprehensive care. From an operational perspective though, primary care teams are often challenged managing these multiple screening needs and tools. And patients can feel overwhelmed by the length of surveys and questions related to sensitive issues such as housing, food security, and substance use.
Photo: Dr. Jagruti Shukla, Primary Care Director, LAC+USC Medical Center
To support this work, SNI convened systems in May to tackle operational problems through peer sharing activities and discuss which screening modalities work best, including how to coordinate screening for multiple needs.
Alameda Health System, UC San Francisco, Los Angeles County and University of Southern California (LAC + USC) Medical Center, and Santa Clara Valley Medical Center shared how they integrate behavioral health and social needs screenings with physical health, and how to address the needs of patients identified during screening.
For example, LAC+USC Medical Center implemented a universal screening approach in primary care, with extensive training for providers and an expanded care team that includes community health workers, social workers, psychiatric consultants, substance use counselors, and others. Within two years, the program, which won a Quality Leaders Award in 2018, led to a 20% reduction in emergency room visits and a 40% reduction in hospital admissions.
Workshop attendees took home tools to better integrate screening processes, and learned more about how to establish partnerships that address their patients’ social needs.
By the Numbers
Advancements in Disparities Reduction Efforts Through PRIME
Beginning in 2016, California’s public health care systems launched a statewide effort to address disparities in health care. Through PRIME, systems are required to improve the collection and stratification of Race, Ethnicity, and Language (REAL) data and collect data on Sexual Orientation and Gender Identity (SOGI) – and for REAL data, which is more established, act on this data.
By the end of PRIME’s third year, systems collected detailed REAL data for more than 638,000 patients – an additional 345,000 patients since program year one (See Figure 1). California, like many states, is in the early stages of SOGI data collection. During the first year of SOGI implementation, systems focused on building the infrastructure for data collection. Now, two years in, systems have collected SOGI data on nearly 279,000 patients (See Figure 2).
The figures further demonstrate public health care systems’ progress in advancing REAL data collection and taking the important step towards collecting SOGI data. Most importantly, these efforts have allowed systems to better identify the diversity of their patient population, identify and implement solutions to address disparities, and provide more tailored care.
Learn more about member progress in our recent brief highlighting disparity reduction advancements driven by PRIME.
Whole Person Care Spotlight
San Mateo County Health’s Whole Person Care Program
This summer, SNI was honored to present alongside the Los Angeles Department of Health Services (LA DHS) and San Mateo County Health (SMCH) on successes in Whole Person Care. During the session, SNI provided an overview of the program and leaders from LA DHS and SMCH described their local pilot initiatives and early outcomes. Ms. Sandra Kiapi, Management Analyst, discussed two projects that have been especially successful at SMCH: Bridges to Wellness Team (BWT) and Integrated Medication Assistance Treatment (IMAT).
The BWT serves individuals with dually-diagnosed Serious Mental Illness (SMI) and Substance Use Disorder (SUD), who are also homeless/unstably housed, or being released from jail. Using a community health worker model, BWT provides intensive case management including same day primary care appointments, expedited behavioral health appointments, housing navigation, and linkages to benefits and community resources, and other support services.
Among the top 20 highest utilizers served by BWT, Emergency Department (ED) visits decreased by 56% from 2017 to 2018. For the entire BWT population, over the same time period, ED visits decreased by 6% and 51 patients were placed in permanent supporting housing in 2018.
IMAT serves individuals with SUD diagnosis, as well as those who are dually-diagnosed SMI and SUD, who are also homeless/unstably housed, or being released from jail. Using interdisciplinary IMAT teams to conduct outreach in the field, SMCH saw promising outcomes for patients with alcohol and/or opioid use disorders, six months after enrollment in the program. For example, results include an 88% reduction in inpatient hospitalizations, 53% reduction in ED and psychiatric emergency services utilization (see Figure 3), and 175% increase in outpatient services.
WPC pilots continue to learn from one another through various venues including the State’s Learning Collaborative and ongoing SNI member support events.
For more information about SMCH’s WPC pilot, visit their website.
What’s Next
Highlights from SNI Programs in the Upcoming Quarter
Improving Patient Inreach & Outreach – On August 15, SNI will host ambulatory care and data leaders at a workshop on improving patient inreach and outreach practices, with a focus on assigned-not-seen patients. For more information, contact Kristina Mody.
Whole Person Care – On August 13, SNI will host a webinar for local WPC evaluators to share their work and address technical issues related to local evaluation projects (not the statewide evaluation). For more information, contact Amanda Clarke.
Data – SNI will host virtual EHR user group meetings this summer to learn from systems that are well-established on Epic. For more information, contact Kristina Mody.
Care Delivery – SNI is partnering with national experts on upcoming webinars, including the Camden Coalition and their 7-Day Pledge to reduce hospital readmissions, and the California Department of Public Health on improving patient screening for chlamydia. For more information, contact Kristina Mody.
Learn More
Read about disparity reduction advancements driven by PRIME in our recent brief.
Save the Date for the CAPH/SNI Annual Conference, December 4-6, in San Diego. Registration will open in September.
Follow CAPH/SNI program updates and recent publications on Twitter @CAPHSystems.
CAPH/SNI members can access program materials through SNI Link– our members’ only program portal.
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By the end of PRIME’s third year, systems collected detailed REAL data for more than 638,000 patients – an additional 345,000 patients since program year one (See Figure 1). California, like many states, is in the early stages of SOGI data collection. During the first year of SOGI implementation, systems focused on building the infrastructure for data collection. Now, two years in, systems have collected SOGI data on nearly 279,000 patients (See Figure 2).
The figures further demonstrate public health care systems’ progress in advancing REAL data collection and taking the important step towards collecting SOGI data. Most importantly, these efforts have allowed systems to better identify the diversity of their patient population, identify and implement solutions to address disparities, and provide more tailored care. 
Among the top 20 highest utilizers served by BWT, Emergency Department (ED) visits decreased by 56% from 2017 to 2018. For the entire BWT population, over the same time period, ED visits decreased by 6% and 51 patients were placed in permanent supporting housing in 2018.