California Health Care Improvement Projects (CHIPs)

Improving Access to Mental Health Services in L.A. County Schools

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. Public school systems in Los Angeles struggle daily with mental health crises for individual students and with their cumulative impact on the learning environment. In 2018-19 there were 7,661 incidents of suicidal ideation on campuses in the L.A. Unified School District alone.

The School Behavioral Health Incentive Program (SBHIP) provided the opportunity for Medi-Cal health plans to earn implement programming to help address this crisis. This CHIP project aimed to improve access to mental health services for children and adolescents in school districts across L.A. County. L.A. Care Health Plan collaborated with Health Net and the L.A. County Office of Education to plan, pilot, and implement a $24 million project to bring telehealth services to students in multiple L.A. County school districts.

Partnerships for School Health Care Requirements

My initial point of inquiry was to better understand what we mean by “equity” and how to operationalize it. In June 2020, employees throughout San Mateo County Health walked out to collectively grieve the murder of George Floyd by police and publicly commit to dismantling the structural racism within our health care system. But what would this look like? How could we translate broad statements into actual wellbeing for our communities? For me, we needed to start by asking our patients and communities these questions and collaborating to implement solutions. If patients determine our health care system’s improvement priorities and co-create solutions, we ensure that those most impacted drive solutions responsive to their experiences. While laying groundwork for community engagement, an urgent need arose with which we could pilot our efforts to pilot equitable care: nearly 1,000 students, mostly Latinx and uninsured, were being excluded or threatened with school exclusion due to school vaccination status. In a novel partnership, the health department, county medical center, and county office of education collaborated to develop temporizing solutions including pop up vaccine clinics, direct scheduling opportunities, and policy guidance discouraging school exclusion.

These measures mitigated the immediate problem, but the county needed to address structural health care inequities to prevent recurrence. I convened a steering committee representing schools, clinics, the health department, and the health plan. We interviewed families who came to these clinics to understand the barriers that resulted in school exclusions despite their efforts to meet requirements. This led to three arms of work: 1) standardized communications to communities, and between health and schools; 2) health care access with specialized services for newcomer students and families, and new mechanisms for schools to connect students to appointments; and 3) learning communities for school staff to support each other with health-related services. So far, this academic year, we have identified fewer school exclusions, have decreased wait times for health care appointments within the safety net clinics, and continue to push coordinated communication to prevent school exclusion.

Developing an Advanced Practitioner Training Academy

California is in a critical primary care shortage. In 2018 an estimated 45% of Californians had insufficient access to a primary care provider. This lack of access leads to increased morbidity, mortality and cost of care. This shortage is reflected in my own organization Neighborhood Health Care, an FQHC in San Diego. To effectively care for all of our assigned patients, we needed to expand our current workforce by 20%.

In 2020 we attempted to recruit clinicians, but numerous positions remained vacant for months, with no physician or experienced advanced practitioner applicants. There were, however, numerous new-graduate advanced practitioner applicants. These candidates were enthusiastic and mission-oriented but lacked experience and suffered disruptions in their training due to COVID.

In my CHIP I developed a training program to prepare recently graduated advanced practitioners to care for our complex patient population. The Advanced Practitioner Training Academy (APTA) focuses on providing high quality, evidence-based primary care, an excellent patient experience and easy access to appointments. Training consisted of precepted continuity clinics, specialty rotations and didactic sessions.