Whole Person Care Lays Groundwork for Quick COVID-19 Response

The COVID-19 pandemic has shined a light on the value of cross-sector partnerships, particularly when caring for vulnerable communities. Strong partnerships open the lines of communication across service providers, and allow counties to respond more quickly during a crisis. Whole Person Care (WPC), a five-year program under California’s 1115 Medicaid waiver, has been leading the way in this regard. Operating across 26 counties, WPC provides a statewide model for building cross-sector partnerships, bringing together public health care systems, behavioral health providers, and social service organizations to improve care for people with complex health and social needs, particularly those who are homeless and most vulnerable to the virus.

In this article, we highlight how WPC pilots in Alameda, San Francisco, and San Joaquin leveraged their cross-sector partnerships and data sharing arrangements during COVID-19 to respond to the urgent needs of those most vulnerable.

Activating Cross Sector Partnerships to Respond to COVID-19

When COVID-19 emerged in California, WPC pilots hit the ground running, leveraging partnerships and resources to rapidly identify those most vulnerable and keep them safe. “The relationships in place from Whole Person Care were turbo charged to respond quickly to COVID,” shared Dara Papo, Care Coordination Services Manager, San Francisco WPC pilot. Similarly, Natascha Garcia, WPC Program Manager in San Joaquin, said, “the experience of working together with [WPC] partners created a solid foundation… we knew who to reach out to… and that was the first thing that allowed us to move quickly.”

Street Outreach

In Alameda, WPC partnered with community-based organizations to deploy multidisciplinary street medicine teams to over 300 homeless encampments, providing individuals with onsite COVID-19 testing and other support services. They also formed a dedicated team to respond to COVID-19 positive cases at homeless encampments. “Typically, the public health department or a hospital will call Whole Person Care, saying, for example, ‘Joe tested positive and was living on an encampment on 12th street,’” said Kathleen Clanon, MD, Director of Alameda’s WPC pilot, AC Care Connect. “WPC teams then go to the encampment to assess the situation – they interview people at the site, arrange for food and medication delivery, distribute face coverings, and provide guidance to support shelter in place if they choose not to transfer into a quarantine hotel.”

Similarly, San Francisco’s WPC pilot leveraged existing partnerships with the Health and Human Services Agency (HSA), Department of Homelessness and Supportive Housing (HSH), and the SF Homeless Outreach Team (SF HOT) to address COVID-19 among individuals experiencing homelessness. “Along with SF HOT, our street medicine and COVID deployment teams are out there trying to find those individuals who are most vulnerable and get them into an interior location to shelter-in-place,” said Carol Chapman, WPC Care Coordination Data Manager. San Francisco also has a new initiative that moves unsheltered individuals into locations where they can more easily spread out and self-isolate while living on the streets. According to Chapman, this includes relocating people living in tents and providing education on how to safely socially distance.

For San Joaquin, the WPC relationships with Behavioral Health Services, Public Health Services, and San Joaquin County General Hospital, in particular, played a critical role in their COVID-19 response. “We were able to utilize our outreach teams, which focus on engaging homeless individuals and those at-risk of homelessness, and add another layer of support for COVID,” said Garcia. “The outreach teams perform a wide range of services, including connecting individuals to community services, housing, and providing medical and behavioral health care.” High-risk individuals are moved to locations to shelter-in place to avoid exposure, while COVID-19 positive patients are sent to a local shelter for further monitoring and care.

Coordination of Services at Isolation/Quarantine Hotels and Shelters  

WPC pilots also played a central role in coordinating services for individuals in shelters, as well as in the isolation and quarantine hotels, known as I/Q hotels, funded through Governor Newsom’s Project Homekey initiative (previously called Project Roomkey). The Governor’s $150M initiative aims to house homeless individuals in hotel and motel rooms across the state so they can safely shelter in place during the pandemic.

AC Care Connect’s strong relationship with housing and homelessness providers allowed them to quickly utilize the resources available through Project Homekey. “When we were suddenly gifted two isolation and quarantine hotels, we had the tools handy to quickly check in with coordinated lead partners, and at one point, air-lifted 150 people in the space of a couple of days,” said Clanon. “It wouldn’t have happened without these existing relationships.”

San Joaquin’s WPC pilot played a key role in coordinating services at several local shelters in partnership with the District Attorney’s office. “We partnered with Community Medical Centers, a local health care system, to provide medical screening, and with San Joaquin General Hospital to provide testing for staff and individuals at the shelter,” said Garcia. “Our ability to place Whole Person Care teams within the local shelters, particularly Gospel Center Rescue Mission and Stockton Shelter for the Homeless, was critical, allowing for a higher level of engagement among those receiving care.”

Many of the individuals placed in I/Q hotels have complex health and social needs, such as severe mental illness and substance use disorder, in addition to being COVID positive or at high-risk for COVID. WPC care pilots leveraged their relationships with behavioral health and social service providers to provide onsite care management and wrap-around support at I/Q hotels, so that clients could continue to access critical services as they shelter in place.

For example, San Francisco implemented a support system for individuals with behavioral health needs who are staying at shelter-in-place sites. At these sites, San Francisco Behavioral Health Services (BHS) provides low-threshold engagement and assessment, which means the barriers that have historically prevented individuals from accessing shelter and care, such as intoxication or pet ownership, are no longer deterrents. Community-based organizations also provide peer support and intensive case management by phone, online, and in-person at the hotels. According to the BHS System of Care lead (and Deputy Director, Forensic/Justice Involved BHS), Robin Candler, “all of this work has been instrumental in meeting the needs of individuals who sometimes have been out of care, and hard to reach on the streets, for many years.”

A Foundation for Action: The Role of WPC’s Data Infrastructure in the COVID-19 Response

Every WPC pilot pointed to the importance of data sharing to rapidly disseminate information and reach those most in need during the public health emergency. The countywide data infrastructure established through WPC provided the tools for counties to quickly communicate and respond to COVID.

Identifying Vulnerable Individuals During the Public Health Emergency

San Francisco’s WPC data infrastructure is the product of strong partnerships across the Department of Public Health (DPH), HSA, HSH, and others. To respond to COVID-19, San Francisco developed a risk assessment tool, based on national CDC guidelines, which enables rapid identification of the highest-risk individuals in the database and locating them based on current residence. “It allowed us to match where these people are, who is most vulnerable, and how many people are still on the streets that we need to place,” said Chapman. “WPC is the only way we can link all this information together.” Similarly, Papo described how established data arrangements were essential to San Francisco’s response. “The fact that DPH has a data sharing agreement in place, and the privacy officer is aware of how information can be shared is because of Whole Person Care – it really allowed us to hit the ground running.”

AC Care Connect utilized their social health information exchange and community health record (SHIE/CHR) in a similar manner. The SHIE/CHR connects five county and twenty community partners and incorporates medical, behavioral health, and housing data from multiple sources. Using a list of people experiencing homelessness within the county’s Homeless Management Information System (HMIS), known as the “by-name” list, they were able to quickly identify who was most vulnerable. “We created a flag to say this person is eligible for a hotel and if they showed up anywhere in the system, the provider would then be able to see and know they are eligible for shelter-in-place support,” said Clanon. “Because of the community health record, providers at Highland Hospital were able to identify eight individuals over the past two weeks who were eligible for the I/Q hotel and immediately transported them.” The flag also notifies providers, such as housing managers, complex care managers, mental health providers, and others, when an individual is placed in the I/Q hotels so they can reach out immediately to provide services.

To fast track care coordination at shelters in San Joaquin, the WPC pilot leveraged their existing WPC consent form. Prior to the pandemic, San Joaquin, like other WPC pilots, led a multi-agency effort to create a culturally appropriate, easy to read form to share client data for purposes of care management and coordination of services. At San Joaquin, the consent form is typically used to coordinate care across twenty different providers. Having the consent form in place when COVID-19 hit, allowed the care teams to quickly establish a data sharing pathway. “We are using the consent form to share information across providers, and the WPC database itself for the COVID-19 response, so getting everyone in and tracked is allowing for the necessary care coordination,” said Garcia. The pilot additionally leveraged their care coordination platform to share medical, behavioral health, and social services data between providers. “We went live with our care coordination platform in April 2019 and it quickly became the best option to share information during the COVID-19 response,” said Garcia.

Conclusion

In California, WPC has played a critical role in protecting and serving those most vulnerable. The COVID-19 crisis further highlights WPC’s essential role, particularly the value of strong partnerships and data infrastructure that improve care for complex and high-risk populations. Unfortunately, these foundational elements typically are not covered by Medi-Cal, and, with the looming expiration of the 1115 Medicaid waiver and delay of CalAIM, WPC faces an uncertain future. It is critical that WPC pilots continue to be leaders, including in the COVID-19 emergency response, bringing their expertise in caring for homeless and other vulnerable populations to the forefront, and supporting those most in need.