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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.


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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.

A critical factor in the success of this program will be getting various entities to work together to identify participants and serve them no matter where they are, and the ability to share data will be paramount to this effort.

Building the IT Infrastructure to Support County-Wide Coordination

High-risk individuals may have multiple case managers working across multiple settings, which raises the need for information sharing, Hong points out. From an IT perspective, the WPC-LA program is being deployed in phases, and one critical piece is the design of a robust, front-end interface for the WPC-LA clinical teams, Hong says. WPC-LA has partnered with Eccovia Solutions, a Salt Lake City-based provider of healthcare coordination platforms, to deploy its ClientTrack Care Coordination tool in order to build what Hong calls the Comprehensive Health Accompaniment and Management Platform (CHAMP).

The platform enables L.A. County’s WPC pilot to bridge the gap between primary care and community services by incorporating the social determinants of health into healthcare decisions and to share patient information across multiple agencies.

“That platform has a core set of functionalities, which includes the care plan, our comprehensive assessment and our encounter documentation pieces,” Hong says, noting that the flexibility of the platform enables multiple case managers and individuals involved in care to access the same care plan through a portal. “For instance, if we wanted to refer someone to a food program like Snap, we could follow the status of that through one platform so we don’t have multiple case managers in three settings submitting applications,” Hong says.

“In the meantime, while we’re working on that, [Eccovia Solutions] also is working on a handful of different issues, such as our housing navigation platform that’s embedded within Housing for Health, and our benefits advocacy platform, so those are three big pieces,” Hong says. Housing for Health is a department within L.A. County DHS.

Hong says the next major step on the IT side will be the data integration phase. “We’re thinking about building out a hub infrastructure, sort of an exchange infrastructure that will then be used to move information to and from CHAMP. And, we’re taking an enterprise perspective; we’re really looking at not just CHAMP, but how CHAMP fits into the bigger sphere of databases and platforms we want to integrate into the hub,” he says, noting that this “exchange hub” could entail leveraging a network of health information exchanges (HIEs) that already exist in L.A. County.

Dario Benavidez, chief program officer at Eccovia Solutions, notes that the Whole Person Care-Los Angeles initiative is a “large scale project” and once all the pieces are in place, the goal is to bridge the gap between organizations and incorporate social determinants of health data into healthcare decisions. Right now, project leaders are still parsing the IT and data challenges.

 “I think the biggest challenge we’ve had is just the scope, scale and speed of the project. We’re supposed to go from zero people and no program to 1,400 people per month enrolled. To do that, we need to enable all of these pieces, and the IT pieces are a critical component of that,” Hong says, adding, “It’s not so much just one piece of it; we need 10 pieces built at the same time. That’s the uniform biggest challenge that we have.”

The data integration piece brings a whole host of other challenges that will need to be worked out around consent and authorization, data sharing, participating agreements between organizations and how the IT platforms interface with each other, Hong notes.

There are several similar initiatives across the country trying to better coordinate health and social services for high-risk, high-need individuals. Hong points to a program in Boston called Prevention and Access to Care and Treatment that seeks to integrate community health workers into primary care and mental health teams, as well as OneCare Vermont, a statewide accountable care organization (ACO), and the New York Delivery System Reform Incentive Payment (DSRIP) program.

“It’s remarkable how similar the functionality is that we’re all seeking. We’re getting to a point where we have a sense of what we want, and there’s a number of different vendors that can do that,” Hong says, but then adds, “I would say, the scale of what we are doing in L.A. County, and the breadth of our programs across different areas of need, there’s nothing like it. I don’t think there’s anything close in the country.”




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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.


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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”


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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.



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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

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