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).

In the time since the last SNI Forward, our team has been focused on helping our members achieve success in the Medi-Cal 2020 waiver programs and in their broader delivery system improvement work. No matter what happens in the policy landscape, we know that this work will be needed for our members’ success.

In June, SNI held an Ambulatory Care Redesign workshop in Oakland, bringing together nearly eighty ambulatory care leaders from across California’s public health care systems to hear from each other and experts in the field on care team transformation and improving on specific PRIME metrics. Workshop participants walked away with ideas to implement at home. In post-event evaluations, workshop participants mentioned a wide range of ideas they plan to explore and implement at their organizations, including ensuring blood pressure readings are accurately taken, creating career ladders for medical assistants, utilizing data to drive provider engagement, and implementing standardized training for care team members.

June also saw the release of the PRIME Demonstration Year 12 (DY12) Year-End Reporting Manual, a 1,135 page guide summarizing official reporting guidance, providing answers to potential questions, and highlighting key changes that have been made over the last year for each of PRIME’s 18 projects and 106 associated metrics. CAPH/SNI members can access the manual and hundreds of other resources through SNI Link.

SNI has continued to host regular member- and expert-led webinars on topics ranging from rethinking care team roles and responsibilities, to adapting alternative payment methods (APMs) and other value-based strategies, to the state of health information exchanges (HIEs) in California.

Most recently, SNI hosted “Technology for Health in the Safety Net” (highlighted below) – a daylong in-person convening focused on innovative tech-enabled services that support the transformation objectives of the Medi-Cal 2020 waiver’s Global Payment Program (GPP).

This edition of the SNI Forward is focused on how this spirit of innovation lives in the delivery system improvement work California’s public health care systems are undertaking.  We hope you enjoy it.


Giovanna Giuliani
Executive Director
California Healthcare Safety Net Institute

Innovation in Medi-Cal 2020

Innovation is ingrained in the development and implementation of the Medi-Cal 2020 waiver. In fact, innovation is the stated purpose of the entire Medicaid Section 1115 Waiver process, which is to support an “experimental, pilot, or demonstration project” that promotes the objectives of the national Medicaid program. The cornerstone programs of the waiver all reflect this goal.

Medi-Cal 2020’s Whole Person Care pilot program is aimed at breaking down cross-sector silos and opening lines of communication and data sharing, in order to provide truly coordinated care to the state’s most vulnerable individuals. This is not a new idea, but it has never been tried before nationally at this size and scope.

PRIME‘s innovative metrics push the boundaries of performance measurement by establishing new ways to evaluate activities such as technology-based visits and targeted care coordination for high risk patients, for which there are currently no clinically-vetted and established metrics.

And Medi-Cal 2020’s Global Payment Program (GPP) for the remaining uninsured is a first-of-its-kind payment reform effort to align the way care to the uninsured is financed with the way it should be delivered – in a patient-centered manner, focused on keeping people healthy and out of the hospital. GPP includes financial incentives for the provision of “non-traditional” services, allowing health care systems to receive credit for 35 different services that were previously unreimbursed.

In a few cases, there are non-traditional services that take place in traditional settings – such as outpatient care provided by RNs, PharmDs, or complex care managers.  The remainder are considered “complementary patient support and care,” or “technology-based outpatient.” These services, both high-tech and low-tech, offer care that is often more convenient and comfortable for the patient, and more resource-efficient for the health care system. For the full list, see our Issue Brief on the Global Payment Program.

Here’s what the data tells us about how our members are providing these services.

By the Numbers: Non-Traditional Services in the GPP

In GPP’s most recent final year-end data (Program Year 1 – submitted in March, 2017) nearly all twelve participating public health care systems reported providing non-traditional services. Of these services, the most commonly-reported was case management, with nine systems claiming points. Eight systems reported having provided RN-only visits, and eight also claimed points for PharmD visits.  Of the tech-enabled services, the most commonly reported was patient-to-provider telehealth, with five systems reporting.  This graph displays the services for which four or more members claimed GPP points:


In PY1, public health care systems tracked and reported nearly 375,000 non-traditional services provided to uninsured patients. These services accounted for 12% of the 2.8 million services reported, which also includes nearly 1.3 million primary and specialty care outpatient visits, and around 440,000 outpatient mental health visits.


Technology for Health in the Safety Net Symposium

Attendees of the Technology for Health in the Safety Net Symposium

On August 31, SNI hosted a day-long convening for more than eighty GPP Leads, Ambulatory Care Directors and CIO/CMIOS, who shared strategic and implementation approaches for innovative, non-traditional tech-enabled services that expand and improve care, access, and patient experience.

These patient-centered and value-oriented services specifically support the transformation objectives of the GPP, but also benefit all patients.

Veenu Aulkah, Center for Care InnovationsAttendees of the Technology for Health in the Safety Net Symposium

Veenu Aulakh, Executive Director of the Center for Care Innovations (CCI), began the day with an overview of the lessons learned for adopting tech-enabled services in the safety net. Attendees saw a panel discussion on how to make the business case for technology, learned about different approaches for tracking and coding non-traditional services for the GPP, and participated in a lively activity using design thinking to better understand the patient perspective during tech-enabled service design and implementation.

Leaders from Riverside University Health System (RUHS) and Monterey County / Natividad Medical Center presented on their experiences implementing telephone visits and texting, respectively – and were joined by Kalvin Yu, Chief Integration Officer of the Southern California Permanente Medical Group, who shared lessons learned from implementing patient portals and provider-patient email communication.

Panel: Making the Business Case for Technology (L-R: Veenu Aulkah; Dr. Michael Yoo, Olive View/UCLA; Dr. Mike Aratow, San Mateo Medical Center; Dr. Jennifer Tong, Contra Costa Health Services)

Attendees also had the chance to take part in hands-on demos of tech-enabled services, including tablet-based screening and eConsult platforms.

Member Profile: Riverside University Health System

Riverside University Health System Medical Center

RUHS has been a leader in utilizing tech-enabled services in California’s health care safety net for several years, thanks to its virtual telephone visit program.


“Our county is the size of New Jersey,” says Geoff Leung MD, Ambulatory Medical Director at RUHS. “For many of our patients, coming into one of our clinics can mean finding child care, taking a day off of work, and dealing with transportation challenges.”

“If patients can’t get the primary care they need, often they’ll wait until their conditions get worse, then seek care in the E.R.”

RUHS, like other health care systems, also struggles with demand that can sometimes outnumber the supply of available appointments, leading to access challenges.

These factors led to the creation of a telephone visit program, through which doctors set aside a portion of their time to help patients over the phone, rather than in person.

Not all visits are appropriate to handle in this way, but Dr. Leung says quite a few of them are. For established RUHS patients, discussion of abnormal test results, medication management, or management of certain chronic or acute conditions can be handled in a much more convenient and comfortable way, through a virtual telephone visit.

Telephone visits now account for about 7% of all RUHS primary care clinic encounters, around 8,000 annually. Dr. Leung says the potential is there for telephone visits to grow to account for as much as one third of all primary care encounters.

“We know the value in using available technology to approach care from the patient’s perspective,” says Dr. Leung, “It creates a better experience for them, frees up in-person appointment time at our clinics, and helps keep our community healthier.”

What's next: SNI Programs in the upcoming quarter

PRIME Data Summit: On October 12, CAPH/SNI will host a member data summit for PRIME program leads and data analysts. Attendees will share reporting lessons from their DY12 experience, learn tactics for reporting success in DY13, and learn key concepts to make data actionable.

Waiver Integration Team Convening: On October 25, SNI will host the 7th Waiver Integration Team (WIT) convening. 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. This convening will focus on how systems are analyzing and applying PRIME data and information from other initiatives to align improvement efforts and plan for sustainability. To learn more about the WITs, see the May edition of SNI Forward.

2017 CAPH/SNI Annual Conference: The CAPH/SNI Annual Conference is a place for public health care system leadership, state and local officials and their staff, and representatives from advocacy organizations and foundations to gather, connect, learn, and be inspired. The theme of this year’s conference is Resilient Leadership. The conference will feature networking and learning opportunities for attendees, and keynote sessions with guest speakers who are recognized experts from the worlds of health care practice, policy and politics. Learn more at caph.org/conference and watch for registration to open soon.

Waiver Program Support: SNI continues to hold regularly scheduled webinars and calls for teams and leads of each waiver program to troubleshoot common barriers, and share successful implementation practices, as well as to disseminate reporting guidance and answer frequently asked questions with regard to reporting.

CAPH/SNI members can log in to SNI Link to see resources, materials, and more information related to waiver support.