California Health Care Improvement Projects (CHIPs)

Monterey Integrated Systems Transformation Initiative

People in Monterey County with complex physical health, behavioral health, and social needs often experience fragmented and ineffective care, leading to poor outcomes and high service use and cost. In response to improving health outcomes for our Monterey County residents, Monterey County Behavioral Health launched the Monterey Integrated System Transformation Initiative. This countywide initiative is designed to help all services become aligned with our most important values for the people who need our help the most.

Optimizing Safety-Net Primary Care Access in the Era of COVID-19

Primary care practices in the safety-net face increasing demands for services as the COVID-19 pandemic has elevated health awareness and state initiatives continue to expand Medi-Cal coverage. At Los Angeles General Medical Center (LA General), the largest primary care site within the Los Angeles County Department of Health Services (DHS), we noted that the years of deferred care, rapid primary care panel growth, and marked workforce attrition pushed our clinics to the breaking point. Primary care provider visits were backlogged, wait times for appointments were months long, and clinical outcomes and patient experience metrics were stagnant or worsening.

As the stewards of primary care access for nearly 58,000 patients across 9 unique medical homes, we heeded the call to disrupt the status-quo and began our journey to design and implement an alternative model of access to meet the competing needs of our patient population. Our vision was to use human-centered design methodology and understand the needs and experiences of all end-users. Our objective focused on developing an innovative solution that integrated medical home team-based care concepts and virtual health tools and technology to improve primary care visit capacity utilization (reduced % monthly visits not utilized, reduce % visit no-show, reduce third next available appointments [TNAA]) and balance clinical quality outcomes in our Quality Incentive Pool (QIP) Program and reported patient experience scores in the Press Ganey Medical Practice Survey (PG-MPS).

Improving linkage of patients with severe mental health illness to primary care providers with clinical pharmacist intervention

Care coordination among patients with severe mental healtillnessesss has been a long-standing challenge. Patients seen in mental health clinics oftentimes have inadequate control of diabetes, hypertension, and dyslipidemia. In addition, more than 60% of this population also suffers from co-occurring substance use disorders. Without addressing these chronic medical problems, patients with poorly managed medical conditions often were lost to follow-up. The goal of my CHIP is to utilize clinical pharmacists, who have been providing psychiatric medication therapy and treatment of co-occurring substance use disorders, to identify patients who need primary care services. For this pilot, the focus is to connect patients with high HgbA1c to primary care services offered at one of our DHS/DMH co-location clinics in LA County and conduct collaboration case conferences to co-manage this group of high-risk patients. Patients were identified through laboratory results and referrals were made electronically by clinical pharmacists to DHS patient access center. Registration of patients into DHS requires managed care to change primary care provider empanelment, but the process was streamlined by leveraging registration information collected by a clinical pharmacist and made available through electronic referral to DHS patient access center staff. Three metrics are being measured: 1) percentage of patients referred to primary care services 2) percentage of patients successfully made appointments with primary care services 3) percentage of Hgb A1C reduction after 6 months.