Health Policy Brief October 2019 Whole Person Care Improves Care Coordination for Many Californians Emmeline Chuang, PhD, Brenna O’Masta, MPH, Elaine M. Albertson, MPH, Leigh Ann Haley, MPP, Connie Lu, MPH, Nadereh Pourat, PhD ‘‘ Delivery of integrated services may improve the patient experience and reduce health SUMMARY: California’s Whole Person Care (WPC) Pilots implemented under the Section 1115 Medicaid Waiver, “Medi-Cal 2020,” are designed to coordinate medical, behavioral, and social services to improve the health and well-being of Medicaid beneficiaries with complex needs. We examined literature on implementation in eight key areas. Three years into the program, results show that WPC Pilots successfully implemented many essential care coordination processes, but they continued to further develop needed infrastructure. These findings highlight opportunities and challenges in implementing a cross-sector care ’’ care use and costs. care coordination and developed a framework for assessing the progress of WPC Pilot coordination program for patients with complex health and social needs. T he U.S. health care delivery system has long been fraught with inefficiencies rooted in part in fragmentation of care and aim of WPC is to improve coordination of medical, behavioral health, and social services for patients who use a high level of Medi-Cal professional silos. Frequently, patients with services and ultimately improve patient chronic and complex needs must navigate health and reduce Medi-Cal expenditures. between medical, behavioral health, and social service providers who are not prepared A total of 25 pilot programs in 26 selected or equipped to provide them with holistic countiesa (hereafter referred to as WPC Pilots) care. Preliminary evidence suggests that were established by 2017. All WPC Pilots delivery of integrated services may improve were led by a single, designated lead entity the patient experience and reduce health care (LE), typically a county Health and Human use and costs.1-3 Services Agency. These LEs partnered with health plans and other service providers In 2016, California began implementing to coordinate medical, behavioral health, the WPC Pilot demonstration project to and social services for targeted Medi-Cal promote systematic delivery of coordinated beneficiaries. Specifically, WPC Pilots were care and evaluate its impact on health care expected to systematically identify target costs and use for Medicaid (called Medi-Cal populations, share data, coordinate care, in California) beneficiaries.4,5 The WPC Pilot and evaluate improvements in the health of is part of California’s Section 1115 Medicaid enrolled populations. waiver, known as “Medi-Cal 2020.” The a Twenty-seven counties initially implemented WPC Pilots, but Plumas County (part of the Small County WPC Collaborative with Mariposa and San Benito Counties) dropped out in September 2018. 2 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Effective cross- sector care coordination requires timely sharing of Acknowledging heterogeneity in how publicly funded services are structured and delivered across California, WPC Pilots had considerable flexibility in the selection of target populations, outreach methods, services provided, and outcomes tracked. WPC Pilots also differed significantly in Care coordination staffing that meets patient needs. To successfully coordinate care across sectors, staff must have sufficient capacity to effectively engage with patients to address a wide range of medical, behavioral, and social needs. Staffing levels appropriate for meeting patient needs include (1) developing information the amount of WPC funds requested and a multidisciplinary team with relevant and among the care allocated to develop infrastructure for care coordination.6 Information on specific diverse clinical expertise, (2) inclusion of peers with lived experience to build trust coordination team characteristics of each WPC Pilot is provided and promote compliance of complex patients, ’’ and providers. in Appendix 1: https://healthpolicy.ucla. edu/publications/Documents/PDF/2019/wpc- appendix-datatable.pdf. and (3) staff workload that ensures sufficient availability to meet patient needs.10-12 Data sharing capabilities to support care What is Care Coordination? coordination. Effective cross-sector care The Agency for Healthcare Research & coordination requires timely sharing of Quality (AHRQ) defines care coordination information among the care coordination as “deliberately organizing patient care team and providers. Data sharing activities and sharing information among infrastructure that facilitates this type of all of the participants concerned with a information exchange includes (1) formal patient’s care to achieve safer and more agreements that define terms and conditions effective care.”7 Care coordination is distinct of data sharing with key partners; (2) a from care management, which is more universal consent form to reduce barriers to focused on management of chronic medical sharing patient data; (3) use of an electronic and psychosocial conditions, and from case data sharing platform that includes key management, which includes services that information such as comprehensive care help patients develop skills to access services plans; (4) medical, behavioral health, and and meet their basic needs.9 We drew on social service use data; and (5) capacity to elements of care coordination identified track and report care coordination activities. by AHRQ and an extensive review of the Ideally, care coordinators can also access this literature to develop a framework of elements data sharing system to (6) view and enter data critical for cross-sector care coordination. (7) remotely (i.e., in the field) and (8) in real- We then used this framework to assess care time.13-15 coordination under WPC. Standardized organizational protocols to support Cross-Sector Care Coordination Framework care coordination. Standardized protocols help Cross-sector care coordination requires minimize undesirable variation in delivery availability of infrastructure to support of care coordination services.16 These include delivery of effective care coordination protocols for (1) referring patients to needed processes (Exhibit 1). medical, behavioral, and social services; and (2) monitoring receipt of services and Care coordination infrastructure elements tracking patient outcomes. include (1) care coordination staffing that meets patient needs, (2) data sharing Financial incentives to promote cross-sector care capabilities to support care coordination, coordination. Financial incentives can facilitate (3) standardized organizational protocols to organizational buy-in and accountability for support care coordination, and (4) financial cross-sector care coordination.3,17 Financial incentives to promote cross-sector care incentives that help align organizational coordination. priorities with these care coordination goals UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Cross-sector Care Coordination Framework Conceptual Framework of Cross-Sector Care Coordination Exhibit 1 Cross-sector care care coordination isfrom the ground Cross-sector coordination is built built from the up, starting with starting with a strong that supports ground up, a strong infrastructure infrastructure the that coordination team as they carry out care they care supports the care coordination team as coordination processes. carry out care coordination processes. Conduct needs assessments and develop comprehensive care plans Actively link Ensure frequent patients to communication and needed services follow-up to across sectors engage enrollees Promote accountability within the care coordination team 3. Process Elements 2. Care Coordinator and Team Care coordination Data sharing Standardized organizational Financial incentives staffing that meets capabilities to support protocols to support to promote cross-sector patient needs care coordination care coordination care coordination 1. Infrastructure Elements include use of payment mechanisms that adoption of patient-centered communication (1) are risk-stratified and address financial strategies. These include outreach or other risk assumed by providers and (2) reward contact with patients (1) in-person, at least better performance via incentive payments. initially, to build trust and engagement; (2) wherever and whenever they can be found, Care coordination process elements include including in the field; and (3) frequent (1) ensuring frequent communication and follow-up, i.e., more than once per month.18 follow-up to engage enrollees, (2) conducting needs assessments and Conduct needs assessments and develop developing comprehensive care plans, comprehensive care plans. Full assessment of (3) linking patients to needed services and patient medical, behavioral, and social needs follow-up to ensure receipt of services, is essential to developing a comprehensive and (4) following protocols to promote care plan. These care plans identify patient accountability among care coordination teams. goals, the actions needed to achieve these goals, and resources or supports needed Ensure frequent communication and follow-up to to ensure successful delivery of care.14,15,19 engage patients. Effectively engaging complex Patients should have a single care plan shared patients in care coordination requires the across all providers that is updated regularly 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2 Care Coordination Infrastructure in WPC Pilots San Bernardino San Francisco Contra Costa San Joaquin Los Angeles Sacramento Santa Clara Mendocino Total Pilots San Benito Santa Cruz San Mateo San Diego Care coordination Monterey Mariposa Riverside Alameda Sonoma framework element Ventura Orange Solano Shasta Placer Marin Kings Napa Kern Care coordination infrastructure Care coordination staffing that meets patient needs N, MH, CHW, MA, C, BS, H, MD CHW, N, SW, C, MH, BS, H C, BS, MH, SW, H, CHW, N SW, CHW, H, MH, C, BS N, MH, BS, H, C, CHW N, MH, C, H, BS, CHW CHW, N, MH, MD, SW CHW, SW, N, MD, MH N, MH, SW, C, H, BS CHW, N, SW, MD, H SW, CHW, MD, H, N SW, CHW, MH, N, H CHW, SW, N, MD, C CHW, BS, H, MH, C Multidisciplinary care MH, N, MD, H, SW MA, N, SW, MH, H MH, N, SW. CHW – coordination team composition* CHW, C, N, SW CHW, N, SW, H MH, CHW, N MA, MD, SW N, SW, BS, H CHW, SW CHW, N SW SW Use of workers with lived • • • • • • • • • • • • • • • • • • • • 20 experience = 20-30 Median 125-150 90-350 70-100 15-150 Workload** 10- 50 20-30 10-20 15-40 17-30 20-25 15-20 10-60 25-75 10-25 20-30 12-30 20-25 8-10 40 40 15 50 25 20 15 60 Data sharing capabilities to support care coordination Some=11, Data sharing agreements among None=0 All=15, key partners Some Some Some Some Some Some Some Some Some Some Some All All All All All All All All All All All All All All All Universal consent form • • • • • • • • • • • • • • • • • • 18 Electronic capture of • • • • • • • • • • • • • • • • • • • • • • 22 comprehensive care plan Frontline staff track and report on care coordination activities in a • • • • • • • • • • 10 single electronic system Read and write access to shared • • • • • • • • • • • • • • • • • • • • • 21 data for frontline staff Real-time access to shared data • • • • • • • • • 9 for frontline staff Remote access to shared data for • • • • • • • • • • • • • • • • • 17 frontline staff Access to medical, behavioral • • • • • • • • • • • • • • • • • 17 health and social service data Data Source: WPC applications, mid-year and annual narrative *Types of staff directly involved in care coordination: reports submitted by WPC Pilots to the California CHW=Community Health Worker or Peer Support, Department of Health Care Services, interviews MA=Medical Assistant, N=Nurse or Licensed Vocational conducted with representatives of each Pilot from Nurse, SW= Social Worker, C= Alcohol and Drug Counselor, September 2018 to March 2019, and surveys of MD=Physician or Nurse Practitioner, MH=Mental Health WPC organizations administered in the summer Professional/Counselor, BS=Benefit Support (includes job and fall of 2018. support), H=Housing Support. **Workload refers to the average number of enrollees per care coordinator. Wide workload ranges were typically associated with WPC Pilots’ use of risk-stratified PMPM bundles, in which intensity of services was tailored based on enrollee risk. In these situations, care coordinators working with higher acuity enrollees often had significantly lower caseloads than those working with lower acuity enrollees. UCLA CENTER FOR HEALTH POLICY RESEARCH 5 Care Coordination Infrastructure in WPC Pilots (continued) Exhibit 2 San Bernardino San Francisco Contra Costa San Joaquin Los Angeles Sacramento Santa Clara Mendocino Total Pilots San Benito Santa Cruz San Mateo San Diego Care coordination Monterey Mariposa Riverside Alameda Sonoma framework element Ventura Orange Solano Shasta Placer Marin Kings Napa Kern Care coordination infrastructure Standardized organizational protocols to support care coordination Standardized referral protocols • • • • • • • • • • • • • • • • 16 Standardized protocols for • • • • • • • • • • • • • • • • • 17 monitoring and follow-up Financial incentives to promote cross-sector care coordination Risk-stratified PMPM bundles† • • • • • • • • • • 10 Contracted care coordination Some=9, None=7 All=10, services (All) Some Some Some Some Some Some Some Some Some None None None None None None None All All All All All All All All All All Financial incentives for • – – • – • • • – – • – – • • • • • • • • 14 contractors†† † Pilots were identified as having risk-stratified PMPM bundles †† Financial incentives for contactors were assessed only when when enrollees were stratified into different PMPM bundles at care coordination services were contracted out rather than intake based on an assessment of risk. provided directly by the lead entity. to address changes in patient needs over time, i.e., more frequently than once per year. Actively link patients to needed services across sectors. Active referral strategies, e.g., through directly arranging services on the patient’s behalf, are more effective in service uptake and case conferences with care coordinators or care teams to share expertise, negotiate differences in judgment, and define priorities for patient care.20 Evaluation of Care Coordination under WPC Data for the evaluation of care coordination ‘‘ Care coordination is most effective when accountability for different than informational referral strategies, under WPC was gathered between activities is such as giving patients information about September 2018 to March 2019 using WPC clearly defined ’’ available treatment options and leaving applications, a structured survey, and follow them to navigate the rest.16 Successful care up interviews with leaders, care coordinators, and monitored. coordination includes active referral to needed and other WPC Pilot staff.b Additional medical and behavioral health, including details about care coordination efforts of mental health or substance abuse treatment, individual WPC Pilots can be found here: and social services such as housing or benefits https://healthpolicy.ucla.edu/publications/search/ assistance. pages/detail.aspx?PubID=1844. Promote accountability within the care Infrastructure coordination team. Care coordination is most WPC Pilots reported significant progress effective when accountability for different in establishing the infrastructure needed activities is clearly defined and monitored. to coordinate the care of enrollees in the Strategies that support accountability for care first 3 years of implementation (Exhibit 2). coordination could include regular meetings b See Data and Methodology section. 6 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Over half of WPC Pilots reported successfully sharing Pilots differed, however, in infrastructure investments, data sharing, and other infrastructure in place prior to WPC. Care coordination staffing that meets patient needs. Staffing varied across and within WPC Pilots based on target population(s) and as emergency department visits, but most WPC Pilots without this capability identified developing real-time notifications as a future priority. Standardized organizational protocols to support care coordination. Around half of WPC Pilots comprehensive identified needs. Care coordination services had standardized protocols in place for were often provided by non-clinical staff referring enrollees to needed services (e.g., medical, such as community health workers. Due checklists) and tracking or following up behavioral to the complexity of enrollee care needs, with enrollees to assess referral outcomes. health, and social however, all care coordination teams included Several WPC Pilots cited the heterogeneity at least some staff with clinical expertise of enrollee service needs as a barrier to services data ’’ (e.g., providers, nurses, social workers). developing standardized referral protocols, with partners. Many WPC Pilots also used peers with lived particularly when referral processes were experience (e.g., previously incarcerated not integrated with an existing electronic or homeless peers) to help build trust and platform to facilitate tracking. Pilots that rapport with enrollees. Staff workload varied contracted out care coordination services considerably across WPC Pilots depending to multiple partners also cited partner on projected acuity of the target population preferences for developing and maintaining and intensity of contact with enrollees. their own internal protocols as a barrier to standardization. Data sharing capabilities to support care coordination. WPC Pilots were required to Financial incentives to promote cross-sector care develop new data sharing capabilities. By coordination. Pilots were primarily reimbursed 2018, all 25 WPC Pilots had at least some for care coordination under WPC using per- formal data sharing agreements with key member, per-month (PMPM) payments for partners. Many had developed universal a bundle of services, though some received consent forms for sharing patient data, and fee-for-service reimbursement to deliver nearly all used an electronic data sharing additional services (e.g., outreach and platform that included information on engagement, assessments and screening). comprehensive care plans. WPC Pilots that Eleven WPC Pilots stratified their PMPM did not yet have these capabilities reported bundles based on enrollee acuity or risk challenges such as vendor delays and and tailored service intensity. The majority difficulty obtaining partner buy-in. Yet they contracted with one or more external typically had temporary solutions to facilitate organizations (e.g., local health clinics or data sharing (e.g., ShareFile, SharePoint, Box) private social services providers) to supply until more efficient and permanent systems some or all of their care coordination could be procured or implemented. Over half services. Of these, over half included of WPC Pilots reported successfully sharing financial incentives in contracts linked to comprehensive medical, behavioral health, the achievement of specific outcomes aligned and social services data with partners. Pilots with WPC goals (e.g., improving quality that did not yet share behavioral health data of documentation or scheduling a follow-up typically identified federal confidentiality primary care visit within 7 days of hospital laws protecting the privacy of substance use discharge). disorder patient records (42 CFR Part 2) as a major barrier. Less than half of WPC Pilots Care Coordination Processes reported providing frontline staff with real- WPC Pilots also reported significant progress time notifications about patient events, such in implementing key processes necessary UCLA CENTER FOR HEALTH POLICY RESEARCH 7 Care Coordination Processes in WPC Pilots Exhibit 3 San Bernardino San Francisco Contra Costa San Joaquin Los Angeles Sacramento Santa Clara Mendocino Total Pilots San Benito Santa Cruz San Mateo San Diego Care coordination Monterey Mariposa Riverside Alameda Sonoma framework element Ventura Orange Solano Shasta Placer Marin Kings Napa Kern Care coordination processes Ensure frequent communication and follow-up to engage patients Enrollee contact more than once • • • • • • • • • • • • • • • • • • • • • • • • • • 26 per month Field-based outreach • • • • • • • • • • • • • • • • • • • • • • • • • • 26 Frequent in-person, on-going • • • • • • • • • • • • • • • • • • • • • • • 23 communication with enrollees Conduct needs assessment and develop comprehensive care plan Needs assessment more than • • • • • • • • • • • • • • • • 16 once per year Single shared care plan • • • • • • • • • • • • • • • • • • • • 20 Actively link patients to needed services across sectors Active referral to medical care • • • • • • • • • • • • • • • • • • • • • • • • • • 26 Active referral to behavioral • • • • • • • • • • • • • • • • • • • • • • • • • • 26 health care Active referral to social services • • • • • • • • • • • • • • • • • • • • • • • • • • 26 Promote accountability within the care coordination team Regular meetings with team to • • • • • • • • • • • • • • • • • • • • • • • • • 25 promote accountability Data Source: WPC applications, mid-year and annual narrative conducted with representatives of each Pilot from September reports submitted by WPC Pilots to the California 2018 to March 2019, and surveys of WPC organizations Department of Health Care Services, interviews administered in the summer and fall of 2018. for effective cross-sector care coordination (Exhibit 3). Their specific approach to these processes varied largely due to their WPC Pilot’s target populations and the level of intensity of services they aimed to provide. Ensure frequent communication and Assess patient needs and develop a comprehensive care plan. WPC Pilots were required to assess enrollee needs and develop a comprehensive care plan within 30 days of enrollment in WPC and, when appropriate, to repeat this process at least once per year. In practice, most WPC Pilots required care ‘‘ Field-based outreach was particularly important for identifying follow-up to engage patients. Many WPC coordinators to re-assess enrollee needs and and engaging Pilots required care coordinators to contact enrollees at least once per month. However, care coordinators in nearly all WPC Pilots update care plans more frequently. To assist with accurate identification of needs, many WPC Pilots reported the use of validated homeless patients. ’’ reported contacting enrollees more frequently instruments such as the Vulnerability Index based on patient need. Most also reported —Service Prioritization Decision Assistance using and prioritizing in-person outreach Tool and the Patient Health Questionnaire-9. in the field rather than contacting enrollees by telephone. WPC Pilots described field- Actively link patients to needed services based outreach as particularly important for across sectors. All WPC Pilots reported use of identifying and engaging homeless enrollees. active referral processes such as accompanying enrollees to appointments or facilitating 8 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Continued investment in data sharing capabilities, staff training, warm hand-offs to medical, behavioral health, and social service providers. WPC Pilots reported perceived benefits of active referral to include the ability to ensure enrollees received important services, provide immediate follow-up after service receipt, and create additional opportunities for care coordination activities, and built financial incentives for performance into contracts with providers. Many WPC Pilots also established care processes to engage enrollees in care, developed comprehensive care plans, actively linked patients to needed services, and promoted accountability among care and other coordinators to interact with enrollees and coordination teams. All Pilots described infrastructure monitor enrollee needs and progress. Among WPC Pilots without standardized protocols WPC as an important opportunity to improve cross-sector relationships and build are needed to for referral tracking and follow-up, active more effective systems of care within their support effective referral strategies were viewed as critical communities. cross-sector care for helping informally “close the loop” on The implementation of WPC included ’’ referrals. coordination. significant and numerous challenges. Pilots Promote accountability within the care acknowledged the need for further progress in coordination team. WPC Pilots were multiple areas to achieve overarching WPC required to identify providers and staff goals of better care, better health, and better responsible for care coordination. Almost efficiency. Our analyses identified specific all WPC Pilots reported use of regular team strategies to address these challenges: meetings to keep one another informed of Invest more time to further develop the enrollee progress and promote accountability infrastructure to support cross-sector care for care coordination activities. A number coordination. Many WPC Pilots had limited of WPC Pilots also reported regular case or no cross-sector data sharing capabilities conferences or other opportunities to prior to WPC. Pilots that successfully created share challenges and brainstorm potential this infrastructure reported investing a solutions. Accountability was generally significant amount of time, typically more described as more challenging in WPC Pilots than originally anticipated, to accomplish where responsibility for care coordination their goals within the first few years of was distributed across many partners. In implementation. Universal consent forms these WPC Pilots, challenges included lack facilitate information sharing, but WPC of consistency in care coordination activities, Pilots noted the need to plan significant the potential for enrollees to have multiple time for review by legal counsel in different designated care coordinators across different organizations. WPC Pilots located in organizations, and a greater need for careful counties in which the majority of services communication during hand-offs across were contracted out to private agencies organizations. emphasized the importance of allocating sufficient time to ensure partner buy-in and Future Steps to align financial incentives within contracts Our interim examination showed many WPC with WPC goals. All WPC Pilots reported Pilots made significant progress in building the importance of continued investment needed infrastructure and delivering cross- in data sharing capabilities, staff training, sector care coordination services. By mid- and other infrastructure needed to support 2018, many WPC Pilots had successfully effective cross-sector care coordination, even hired care coordinators, shared data across mid-implementation. sectors despite multiple challenges, created standardized protocols to support care UCLA CENTER FOR HEALTH POLICY RESEARCH 9 Promote person-centered practices that more analyst at the UCLA Center for Health Policy effectively engage vulnerable patients in Research. Leigh Ann Haley is a project manager and research analyst at the UCLA Center for Health care. Pilots recognized the need for patient- Policy Research. Brenna O’Masta, MPH, is a project centered outreach, communication, and manager and research analyst at the UCLA Center referral strategies to engage enrollees in for Health Policy Research. Nadereh Pourat, PhD, WPC services. Successful strategies reported is associate director of the UCLA Center for Health by WPC Pilots to help foster enrollee self- Policy Research, director of the Center’s Health efficacy included using case management Economics and Evaluation Research Program, professor of Health Policy and Management at in addition to care coordination to more the UCLA Fielding School of Public Health, and effectively serve enrollees, the hiring of professor at the UCLA School of Dentistry. clinical staff that were only funded part- time by WPC to allow for direct provision Acknowledgments of services as part of initial outreach and Funding for this project was provided by the engagement efforts, and providing benefits California Department of Health Care Services. The assistance to help reduce Medi-Cal churn. authors thank Denisse Huerta and Kimberly de All Pilots also reported ongoing adjustment Dios for their assistance in developing case studies of WPC Pilots. We also thank WPC Pilot organizations of WPC programs (e.g., by reducing care for their time and effort spent completing reports, coordinator caseloads or clarifying scope of interviews, and surveys and reviewing our findings. work) to better meet enrollee needs. Data and Methodology Leverage WPC resources and partnerships UCLA developed the care coordination framework to help address structural problems outside following a systematic review of the literature on of WPC Pilots’ control. Multiple WPC cross-sector care coordination. Screening of 1,694 Pilots cited limited availability of long-term, articles identified 27 articles addressing interventions to coordinate health and social services for high-use permanent housing as a barrier. Similarly, patient populations. These articles were evaluated several small and rural counties cited for key themes and trends and directly informed the difficulties with recruitment and retention conceptual framework used in this report. Qualitative of staff and limited availability of private data sources used to assess WPC Pilot care coordination behavioral health providers accepting Medi- activities included WPC applications, mid-year Cal as barriers to timely access to behavioral and annual narrative reports submitted by WPC Pilots to the California Department of Health Care health services. Strategies used by some Services, semi-structured interviews conducted with WPC Pilots to address this issue included key informants from each Pilot between September leveraging WPC to ensure expedited access 2018 to March 2019 (n=27), and web-based surveys or priority placement for their enrollees administered from July 2018 to October 2018 to key and developing innovative partnerships program staff in WPC Pilot Lead Entities (n=27) and to improve availability of services within Partners (n=227). UCLA coded reports and interviews for themes by multiple coders to ensure validity. the community, e.g., working with private Analysis were completed using NVivo 12.0 software. homeowners to place people in new types of Analysis of survey data was completed using Excel and housing. Stata 13.1. Author Information Suggested Citation Emmeline Chuang, PhD, is an associate professor Chuang E, O’Masta B, Albertson EM, Haley LA, of Health Policy and Management at the UCLA Lu C, Pourat N. 2019. Whole Person Care Improves Fielding School of Public Health. Elaine M. Albertson, Care Coordination for Many Californians. Los Angeles, MPH, is a doctoral student in Health Policy and CA: UCLA Center for Health Policy Research. Management at the UCLA Fielding School of Public Health. Connie Lu is a project manager and research UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 Endnotes 12 Nossel IR, Lee RJ, Isaacs A, Herman DB, Marcus 1 Figueroa JF, Feyman Y, Zhou X, Joynt Maddox K. SM, Essock SM. 2016. Use of peer staff in a critical 2018. Hospital-level care coordination strategies time intervention for frequent users of a psychiatric associated with better patient experience. BMJ Qual emergency room. Psychiatr Serv 67(5):479-481. Saf 27:844-851. 13 Reamer FG. 2018. Ethical Issues in Integrated The UCLA Center Health Care: Implications for Social Workers. Health 2 Berry LL, Rock BL, Smith Houskamp B, for Health Policy Research Soc Work 43(2):118-124. Brueggeman J, Tucker L. 2013. Care coordination is part of the 14 Blewett LA, Owen RA. 2015. Accountable care for for patients with complex health profiles in inpatient UCLA Fielding School of Public Health. the poor and underserved: Minnesota’s Hennepin and outpatient settings. Mayo Clin Proc 88(2):184- 194. Health model. Am J Public Health 105(4):622-624. 3 Shier G, Ginsburg M, Howell J, Volland P, Golden 15 Frank RG, Riedel L, Barry CL. 2015. R. 2013. Strong social support services, such as Together4Health: Integrating care for vulnerable transportation and help for caregivers, can lead populations. American Journal of Psychiatric to lower health care use and costs. Health Aff Rehabilitation 18(1):105-127. (Millwood) 32(3):544-551. 16 Carter MW, Wu H, Cohen S, Hightow-Weidman 4 Alley DE, Asomugha CN, Conway PH, Sanghavi L, Lecher SL, Peters PJ. 2016. Linkage and Referral DM. 2016. Accountable Health Communities — to HIV and Other Medical and Social Services: A The analyses, interpretations, conclusions, Addressing social needs through Medicare and Focused Literature Review for Sexually Transmitted and views expressed in this policy brief are Medicaid. New England Journal of Medicine 374(1):8- Disease Prevention and Control Programs. Sex those of the authors and do not necessarily 11. Transm Dis 43(2 Suppl 1):S76-S82. represent the UCLA Center for Health Policy 5 Gottlieb L, Colvin JD, Fleegler E, Hessler D, Garg 17 Amarasingham R, Xie B, Karam A, Nguyen N, Research, the Regents of the University A, Adler N. 2017. Evaluating the Accountable Kapoor B. 2018. Using community partnerships to of California, or collaborating Health Communities demonstration project. J Gen integrate health and social services for high-need, high-cost organizations or funders. Intern Med 32(3):345-349. patients. Commonwealth Fund. 6 Whole Person Care application statistics. 2019. 18 Brown RS, Peikes D, Peterson G, Schore J, PB2019-7 https://www.dhcs.ca.gov/services/Documents/MCQMD/ Razafindrakoto CM. 2012. Six features of Medicare Copyright © 2019 by the Regents of the coordinated care demonstration programs that cut University of California. All Rights Reserved. Whole_Person_Care_Stats_Feb_2019.pdf 7 AHRQ. Care coordination. 2018. https://www.ncbi. hospital admissions of high-risk patients. Health Aff nlm.nih.gov/pmc/articles/PMC4157993/ (Millwood) 31(6):1156-1166. Editor-in-Chief: Ninez Ponce, PhD 8 AHRQ. Care management: Implications for 19 Schor EL. 2019. Ten Essential Characteristics of Care medical practice, health policy, and health services Coordination. JAMA Pediatrics 173(1):5. research. 2015. https://www.ahrq.gov/sites/default/files/ 20 Press MJ, Michelow MD, MacPhail LH. 2012. Care Phone: 310-794-0909 publications/files/caremgmt-brief.pdf coordination in Accountable Care Organizations: Fax: 310-794-2686 9 SAMHSA. Case Management. 2019. https://www. moving beyond structure and incentives. American Email: chpr@ucla.edu samhsa.gov/homelessness-programs-resources/hpr-resources/ Journal of Managed Care 18(12):778-780. healthpolicy.ucla.edu case-management 10 Bielaszka-DuVernay C. 2011. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood) 30(3):383-386. 11 Wang EA, Hong CS, Samuels L, Shavit S, Sanders R, Kushel M. 2010. Transitions Clinic: Creating a community-based model of health care for recently released California prisoners. Public Health Reports 125:171-125.