The two largest patient groups in California are Kaiser members (9 million) and patients served by California’s FQHCs (7 million), but you could not find two more dissimilar health systems. Kaiser and nearly all other health systems organize their providers in medical groups; FQHCs are private non-profits that employ and support their providers independently. The separation between individual FQHCs results in inconsistent access and quality, an inability to retain talent and resources, and diminished voice in the broader health care system.

Chronic diseases (eg: heart disease, stroke, DM, kidney disease, cancer) account for 5 of the top 10 causes of death in our country. Obesity is a well-known risk factor for all these chronic diseases, and we have almost 40% of US adults and 20% of children obese in the US, and the COVID pandemic has only worsened these trends. We currently have outstanding innovations in the field of medicine that focus on medications, delivery methods, and surgeries, yet our communities continue to struggle with chronic disease management and increasing rates of obesity.

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.

Permanent vision loss is prevalent among the aging and will continue to rise. There are gaps and barriers resulting from fragmented care locally and globally. The health inequity among the aging, visually impaired population is also a public health issue with an economic burden on state and federal resources. The CDC reports that 4.5M over age 40 report that they are blind. This number is expected double to 9M by 2050. There are 21M more who reports having “vision problems” not correctable with conventional glasses, contact lenses, or refractive laser surgery.

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.

When someone experiences a crisis – a fire, crime, or medical emergency – they call 911 with the expectation of getting immediate emergency services. However, when that emergency is a behavioral health crisis, there is currently no timely and clinically appropriate response, which too often results in unnecessary suffering, loss of life, criminalization, or incarceration. A3 addresses this enormous need by making behavioral health part of the emergency response system throughout Contra Costa County.