Welcome to 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).

It’s been a rollercoaster quarter for all of us in the health care safety net landscape.

Over the last few months at SNI, while we’ve been helping California’s public health care systems meet the targets and reporting deadlines of the Medi-Cal 2020 waiver programs (PRIME, Global Payment Program, and Whole Person Care), we’ve also held two in-person convenings focused on strengthening foundational capabilities – A Data for Improvement workshop on building data analytics capacity and an Ambulatory Care Redesign workshop on strengthening empanelment efforts.

Necessary for Success

Both of these skills are needed for health care systems to succeed in any landscape, but perhaps even more so in uncertain one.  With the progress we’ve all made being challenged, it’s more important than ever to make sure that our resources are being used as effectively as possible to serve patients – which means it’s necessary that we, and our members, think about improvement efforts in an integrated and coordinated way.

This approach is evident across all of SNI’s member support offerings, but it is truly showcased in our Waiver Integration Team work.  As we discussed in the last SNI Forward, we play three key roles in helping our members succeed.  This work is an example of our efforts to accelerate and support decision-making and learning, within and across member systems.

We hope you enjoy this edition of the SNI Forward.


Giovanna Giuliani
Executive Director
California Healthcare Safety Net Institute

Waiver Integration Teams

Waiver Integration Teams (WITs) are core groups of leaders at each of our member public health care systems, which are responsible for strategic and operational oversight of the Medi-Cal 2020 waiver programs and broader delivery system reform efforts. By design, the WITs are interdisciplinary teams of leaders that bring diverse perspectives to the waiver work. The teams vary by site, but generally they include clinical leaders, finance leaders, data leaders, and quality/performance improvement leaders.

SNI convenes the WITs on a regular basis to ensure that waiver activities align with one another, as well as with other strategic initiatives and organizational priorities.  The WITs also provide a forum where public health care system leaders can network with and learn from one another, and engage in strategic planning with their teams. Previous WIT convenings have covered topics like waiver communications and engagement strategies, and approaches to integrating behavioral health across PRIME, Global Payment Program, and Whole Person Care.

Peer group table discussions - May 24 WIT Convening

May 24 Convening – Value-Based Strategies and Aligning Whole Person Care with PRIME

Nearly 100 people attended our first of three 2017 WIT convenings on May 24, which focused on two major topics.

Alternative Payment Models 

There is strong momentum across the entire health care landscape to more closely tie payments to value, rather than volume.  PRIME, one of the cornerstone programs of the Medi-Cal 2020 waiver, requires that California’s public health care systems use alternative payment models (APMs) in which providers assume some level of risk for the cost and quality of services provided to Medi-Cal managed care enrollees assigned to these health care systems. WIT attendees identified steps needed to meet these requirements, discussed with their peers the impact movement towards value-based care would have on their specific roles, and had the opportunity to learn from the experiences of other health care systems on this same journey.

Panelists Dr. Alice Chen (Chief Medical Officer, San Francisco Health Network) and Sam Perryman (Administrator of Managed Care, San Mateo Medical Center) discuss Alternative Payment Models

Aligning Whole Person Care and PRIME

The second topic was alignment between the Whole Person Care (WPC) program – which aims to improve the health of high-risk, high-utilizing patients through the coordinated delivery of services from across the community – with two PRIME projects, Care Transitions: Integration of Post-Acute Care (2.2) and Complex Care Management for High Risk Medical Populations (2.3). WITs worked in teams to assess how they can best leverage staffing and resources for both programs, and how to ensure that patients are routed to the appropriate care, based on their acuity and needs. WITs also learned about other counties’ WPC programs and shared approaches for coordinating WPC and PRIME.

A WIT attendee sketches out a potential process for aligning WPC and PRIME efforts

By the Numbers: Whole Person Care Themes

As part of the Whole Person Care and PRIME discussion at the most recent Waiver Integration Team convening, attendees saw an analysis of common implementation themes among the eighteen Whole Person Care pilots that have been selected by DHCS.

Services and Interventions


For example, fifteen of the pilots feature a care management component, nine include a focus on wellness and education, and four will make mobile services available to participants.

Member Profile: Contra Costa Health Services

Contra Costa Regional Medical Center - part of Contra Costa Health Services

The goal of the WIT convenings is twofold – to create a dedicated space for teams to discuss these challenges with themselves and their peers, and to help foster dialogues that can continue long after attendees have gone home about how the waiver programs and requirements fit into a bigger picture.

At Contra Costa Health Services (CCHS), the implementation of the Medi-Cal 2020 waiver and the start of SNI’s Waiver Integration Team focus have coincided with the rollout of a long-term strategic plan.

“It could get overwhelming if you look at all of our performance improvement projects separately,” says Karin Stryker, Assistant Director of Safety and Performance Improvement at CCHS, “but when you see them as part of a whole, you see how they all work together.”

CCHS typically sends 6-8 team members to the SNI WIT convenings. Its internal Waiver Integration Team consists of around ten people and meets monthly, on topics like sharing implementation best practices across programs, how to align local resources to support Whole Person Care, and population health governance.  These meetings include leaders from throughout CCHS’s delivery system, as well as representatives from Contra Costa County Health Plan, the county’s Department of Public Health, and others. The County also holds occasional large-scale improvement events, with dozens of additional attendees, focused on larger questions of strategy and vision.

“There’s much more awareness of the impact each of us has on the others, and the importance of coordinating our work,” says Dr. Sara Levin, Physician/Clinician Educator at CCHS. “We can’t achieve what we need to achieve in our silos.”

This philosophy is evident in the County’s Whole Person Care pilot.  Whole Person Care relies on coordination and alignment of services, and Contra Costa County’s pilot is being structured to ensure that information and strategy is also coordinated across the entire health system, as well as with social service providers and out in the community.

“These convenings help shape our conversations and create a focus on certain areas of the waiver. We see we have gaps within our own organization, and we can see what other organizations are doing to address those gaps,” says Shannan Moulton, Health Services Administrator at CCHS.  “We do get trapped in our own worlds, and aren’t always aware of the bigger picture. These meetings are a great reminder to keep communicating.”

What's next: SNI Programs in the upcoming quarter

Waiver Program Support

SNI continues to hold regularly scheduled webinars and calls for teams and leads of each waiver program – PRIME, Global Payment Program, and Whole Person Care – to disseminate reporting guidance, answer frequently asked questions, troubleshoot common barriers, and share successful implementation practices. CAPH/SNI published an Issue Brief on the PRIME program in May, and the final PRIME DY12 reporting manual will be published in June.

CAPH/SNI members can always log in to SNI Link – our members’ only program portal – to see resources, materials, and more information related to waiver support.

Ambulatory Care Redesign

Building off the success of our empanelment workshop in March, SNI will be hosting another workshop in June, focused on team-based care and panel management. We also continue hosting Ambulatory Care Redesign webinars using PRIME’s required projects as case studies. CAPH/SNI members can learn more and download resources from the empanelment workshop and webinars on SNI Link.

Technology in the Safety Net

In August, SNI will be hosting an in-person convening on the use of technology to deliver efficient, patient-centered care. The convening will touch on the use of technology-enabled “non-traditional services” in the Global Payment Program (such as nurse advice lines and texting), as well as those measured by some of PRIME’s “innovative metrics” (such as eConsult.) Additional information and registration materials will be posted soon for CAPH/SNI members on SNI Link.