California Health Care Improvement Projects (CHIPs)

Healing the Streets: Integrated, Person-centered, Street-based Care for People Experiencing Homelessness and Severe Mental Illness in Santa Cruz County

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. The Healing the Streets Program (HTS) set out to test an integrated, person-centered, street-based care model that is not based on offering housing. As a society, we tend to “treasure what we measure;” HTS designed the program uniquely focused on articulating and addressing clients’ goals.

The HTS team of Case Managers, Peers, and a Nurse Practitioner began targeted street-based outreach with an existing physical health street medicine team in February 2022 and started enrolling clients in April. HTS staff utilize motivational interviewing and a “circle chart” depicting potential areas of need (hygiene, food assistance, housing navigation, mental health, etc.) to elicit the client’s goals and begin prioritizing them.

GAIN Project (GAmified INcentives-Based Treatment): Digital Rewards-Based Treatment for Justice-involved Dually Diagnosed Clients

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). Over the last ten years, we have noted a steady rise in methamphetamine use and associated adverse outcomes in our client population, including worsened psychotic symptoms, increased likelihood of arrests or recidivism, increased social challenges (such as houselessness), and increased use of acute psychiatric services. Unlike many substance-use disorders, methamphetamine-use disorder (MUD) lacks an effective medication-based intervention. The only treatment with a clear evidence base is contingency management (CM). However, this treatment has not been widely used because of two challenges, (1) it has only been used experimentally because it financially rewards clients for reducing substance use, which brings up concerns about cost, sustainability, and diversion of funds, and (2) it is administratively complex to implement. The first challenge has been answered. The fact that California will launch a state-wide CM pilot through CalAIM and there is interest at the federal level to make CM reimbursable through public insurance indicates that CM will become a mainstream treatment. T A digital solution can answer the second challenge by using an app that would make CM more scalable by reducing the heavy administrative burden. We have obtained $1M philanthropic funding to develop an app to provide contingency management to our justice-involved clients who struggle with mental health challenges and substance use disorder. This project aims to (1) provide CM to reduce stimulant use, (2) increase digital literacy and access to aim for “digital belonging” for those at the margins of society, (3) support overall recovery goals through gamification and rewards, and (4) clarify implementation steps necessary to provide CM to this highly marginalized population successfully.

A Digital Safety Net Engaging Patients through Automation to Drive Outcomes

“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. PCPs can get burnt out and frustrated trying and failing to keep track of their patients. Our systems then see the cost of care increase.

Working for a primary care practice embedded in a healthcare technology company has opened my eyes to data and technology tools. An added focus on engagement can bolster the traditional healthcare focus on outcomes. With these tools, we’ve created a digital backstop and started to mitigate the “lost to follow up” problem by building a system that continuously engages patients. Notably, we began with a much more specific focus – to improve patent outcomes on key quality metrics (such as rates of cancer screening and diabetes eye exams) but uncovered and are successfully addressing this broader opportunity.

We built a digital safety net – a dynamic data model which keeps track of all empaneled patients and deploys automated patient- and team-facing communication at clinically appropriate intervals. This model is always updating and drives patients back to care. Our goals were: 1) to engage patients with their primary care team at clinically appropriate intervals, 2) to prompt patients to follow through with their care plans, and 3) to promote the healthcare team to reach out to patients when they become overdue for care, to take away the cognitive load of manually tracking patient registries that often burden the care team.