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In L.A. County, Building an Integrated Health System to Serve the Highest-Risk Individuals

September 26, 2017
by Heather Landi
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Within the Los Angeles County Department of Health Services, there is currently an ambitious project underway to build an integrated, county-wide system that will link health and social service agencies, from hospitals to mental health providers to housing entities, to provide more coordinated services to the sickest, most vulnerable residents in L.A. County.

Called Whole Person Care-Los Angeles, the project is a Medi-Cal 2020 waiver-funded program and a five-year initiative to bring together health and social service delivery entities across the largest county, by population, in the U.S., and to deliver seamless, coordinated services to high-risk Medi-Cal beneficiaries who are “high users” of multiple public systems. Medi-Cal refers to the state’s Medicaid program. These high-risk individuals may be homeless, justice-involved, or have a serious mental illness or medical issues, or all of the above, says Clemens Hong, M.D., director of Whole Person Care-Los Angeles and medical director of community health improvement within the L.A. County DHS.

“With this program, we are trying to serve a subset of the highest-risk individuals in our county. These folks often have needs across the entire spectrum,” Hong says. “When you put that all together, it requires us trying to create an integrated delivery system to really break down a lot of the silos that exist in the delivery of services and healthcare delivery to these populations. That is the fundamental challenge of Whole Person Care; to take these entities and service providers, including social services, and really try to work together better and communicate better in order to care for these clients that have these complex needs.”

The program in L.A. County is part of the California Department of Health Care Services’ Whole Person Care Pilot, authorized under California’s Medi-Cal 2020 waiver initiative. Last year, L.A. County was one of 18 entities approved for the first round of the WPC program. The state’s WPC pilot received $1.5 billion in federal funding to distribute to the pilots at the city and county level. An overarching goal of the program is to better coordinate care management to improve the health and wellbeing of these high-risk individuals, avoid duplication of services and reduce inappropriate utilization of hospital emergency rooms and inpatient services.

Broadly, the Whole Person Care pilots are tasked with identifying target populations, sharing data between systems, coordinating care in real-time and then evaluating individual and population progress.

Within L.A. County, which has a population of 10 million across 4,000 square miles, there are approximately 82,000 men, women and children who experience homelessness on any given night. The goal of the WPC-LA pilot is to deliver coordinated wrap-around services to about 60,000 people each year, Hong says. “Some individuals cycle through multiple times, so we don’t know the exact number,” he says.

The pilot is now up and running in L.A. County, with community health works currently out in the field engaging with high-risk individuals. The WPC team members collect information, work to enroll eligible individuals in the program, conduct assessments to identify the individuals’ needs, develop care plans and link the individuals to the appropriate services. The WPC-LA pilot consists of 11 programs serving individuals in five populations—homeless, justice-involved, mental health, substance use disorder and medically high-risk.

A key to this program is to facilitate better communication between health and social services organizations to effectively navigate individuals to the right services in the system.

“Take an individual in the community who is high-risk—they are often the sickest, most marginalized individuals in our community," Hong says, continuing, "These might be people who are homeless, or in and out of prison, or both; they might have a serious mental illness, severe, persistent substance use disorder, or a medical illness, or all of the above. Those folks often touch our system in many different places. They may get incarcerated in our jails, they might hit our ERs over and over again across the county, or they might hit a social service agency over and over again. No matter where they hit our system, the idea is to try to have a set of criteria that people are aware of and they can say, ‘This person may be a Whole Person Care client’ and then refer them in. It’s an ‘any door’ type of approach."

Along with homeless care suporrt services, the eleven programs focus on a range of issues, such as community-based re-entry, residential and bridging care, substance abuse disorder engagement, navigation, and support services, and transitions of care for medical patients.

Individuals identified as medically high-risk, or those with recurring medical hospital admissions, are enrolled in the Transitions of Care program. An evidence-based hospital-to-home care transition approach will be used to support patients as they leave the hospital, facilitate engagement with their primary care team, and create linkages to community-based organizations to support the patients’ social service needs, Hong says.

Hong refers to the Whole Person Care program as the “connector” between county agencies, health plans and providers. “We don’t deliver primary care services and we don’t provide mental health treatment, but we take these high-risk folks and link them to these critical services. The hope is, down the line, they don’t go to the ER as much because they can go to their primary care doctor, or they don’t get incarcerated again because we addressed their underlying social needs,” he says.

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