Imagine an under-resourced place in East San Jose where Vietnamese immigrants live with significant health and social disparities. The community is painfully aware that due to legacy of war, political persecution, and mass displacement, they have been through significant multigenerational trauma. They prioritized and advocated for the building of a trusted place where they can receive mental health services in their own language or through an interpreter that they trust.

The City of Compton, California and community of North Long Beach, California continue to experience extraordinary barriers to lifesaving medical care. With the highest rates of maternal mortality, infant mortality, and homicide in Los Angeles County, these areas lack essential lifesaving medical services including, a high-risk hospital-based birthing center, a neonatal intensive care unit, and a level-one trauma center.

The crisis in adolescent mental health was highlighted in 2021 bulletins from the Surgeons General of California and the United States. Even before COVID, the incidence of adolescent major depression, suicidal ideation, and emergency room visits was on the rise. The profound death toll, sense of fear, economic disruption, and social isolation exacerbated the unprecedented stresses facing American youth. Communities of color were particularly hard hit by the twin pandemics of COVID-19 and systemic racism.

Rather than seeing COVID-19 as an insurmountable obstacle, I, along with my team at Community Health Centers of the Central Coast (CHCCC), Inc., viewed it as an opportunity to accelerate the pace of innovation. To better meet the needs of the community, the CHC Behavioral Health and Psychiatry Departments are committed to moving beyond brick-and-mortar clinics to a ‘click and mortar’ clinic in the sky, the Cielo Center for Integrated Health. Like many health centers CHCCC quickly shifted to virtual care not long after the pandemic emerged.

“Lost to follow up” is a too-common refrain in the ambulatory healthcare setting and is particularly problematic in primary care, whose focus and value lie in an ongoing, longitudinal relationship with the patient. Academic primary care practices often care for socially or medically complex patients and may lose 25-45% of patients to follow-up. Patients, PCP teams, and the system are all impacted differently by this challenge. Patients can experience a decline in their health status and poor outcomes if they cannot access care in ways and at times that are convenient for them.

In 2020, there were 700 overdose deaths in San Francisco, which was more than double the number of COVID deaths. Though the proximal cause of death is Fentanyl, 60% of those who died were using methamphetamines, which means that many of those deaths may have been prevented by targeting stimulant use. UCSF Citywide serves nearly 2000 people annually with serious mental illness (SMI), homelessness, and institutionalization (long-term locked psychiatric hospitalization and incarceration).

CalAIM and recent Whole Person Care pilot programs are redesigning how care is offered to people with complex needs in the MediCal system. Housing First models have demonstrated the importance of housing for client well-being, stability, and health outcomes, yet most communities lack adequate temporary and permanent housing options. Efforts thus far have failed to demonstrate compelling outcomes due to a combination of the small sample size and the complexity inherent in interventions for people who are unhoused and often have severe mental illness with co-occurring substance use disorder.

As behavioral health needs skyrocketed when the COVID-19 pandemic took hold, specialty behavioral health organizations which provide services to people with serious mental illness and/or substance use disorder pivoted to delivering significantly more care via telehealth. While behavioral telehealth access may be a point of pride, racial inequity is also evident in telehealth access. It is disproportionately inaccessible to people of color, in particular those from the Black and Latinx communities, people with limited English proficiency, people facing poverty, and older adults.

The California Advancing and Innovating Medi-Cal initiative created a once-in-a-generation opportunity to reform Behavioral Health documentation. As the Chief of Medi-Cal Behavioral Health with the California Department of Health Care Services, my CHIP focused first on removing complex and cumbersome documentation standards that far exceed the standards of other healthcare delivery systems and replacing them with efficient, effective, and impactful policies to improve the lives of those we serve.

Telehealth has always interested me as a model of care to decrease barriers and increase access to care, but prior to the pandemic state of emergency there wasn’t a reimbursement model for FQHCs in primary care. We were doing some telehealth with remote specialists, bringing patients to the clinic for visits, but nothing in primary care or with remote patients. Then everything changed. Over 2 weeks in March 2020, we went from 100% in-person visits, to only 15%, the remaining 85% remote telehealth.