The emergence of COVID-19 has heightened the need for public healthcare systems, social service agencies, and community-based organizations to work together on an effective, coordinated response. Strong centralized leadership and rapid information sharing across service lines are critical to address the pandemic, particularly for individuals with complex health and social needs who are most vulnerable to the virus. For four years, California’s Whole Person Care (WPC) program has developed the partnerships, data sharing infrastructure, and multidisciplinary teams that are now essential to address COVID-19, and many WPC pilots are playing a central role in their county’s emergency response.
Whole Person Care is a 5-year program under California’s 1115 Medicaid waiver, run through 25 regional coalitions known as WPC pilots. Each WPC pilot brings together county and community partners to identify and serve their highest-risk clients, many of whom face extreme challenges, such as homelessness, severe mental illness, and involvement in the criminal justice system. WPC pilots build the local infrastructure that enables providers to coordinate care across sectors more efficiently. Additionally, under the authority of the 1115 Medicaid waiver, WPC pilots pay for services that are not typically covered by Medi-Cal, yet, show promise for addressing clients’ holistic health and social needs, such as street medicine, medical respite, and jail reentry support.
A recent interim evaluation of WPC shows promising results. The report, released by the UCLA Center for Health Policy Research, uses a mixed methods approach and reports three main findings: improvements in care coordination infrastructure, better care processes, and better health outcomes.
Improved Care Coordination Infrastructure
It is well documented that health care and social service providers traditionally have operated in siloes, too often resulting in less effective, fragmented care. According to the evaluation, WPC pilots made progress toward breaking down these siloes by strengthening care coordination infrastructure. Pilots implemented data sharing infrastructure, such as care management platforms and health information exchanges, which allow for real-time communication between providers and documentation of clients’ holistic health and social needs. Pilots designed global payment bundles (per-member-per-month) for care coordination that afforded flexibility in how, when, and where staff coordinated services so they could be most responsive to clients’ needs. Additionally, pilots established new, multidisciplinary care teams with representation across partnering organizations, many including peer support staff who draw on their personal lived experience and empathy to engage clients (See Figure 1).
Better Care Processes
WPC pilots use the Plan-Do-Study-Act (PDSA) methodology to continually test and improve their care processes, with demonstrable results. For example, in the first year of implementation many pilots adapted their enrollment processes to expand provider referrals and rely more heavily on in-person outreach to engage difficult-to-reach clients, resulting in steady increases in enrollment in Year 2. Pilots are required to report PDSA improvements, as well as metrics that capture changes in care processes. An assessment of process metrics in the evaluation found that, compared to pre-enrollment, WPC clients had: (1) higher rates of follow-up after hospitalization for mental illness; (2) improved initiation and engagement in treatment for alcohol and other drug dependence; and (3) more timely provision of care plans (See Figures 2 and 3). For several process measures, improvements were greater for justice-involved clients. The findings suggest better coordination between physical health, behavioral health, and the criminal justice system, and point to the value of WPC’s high-touch, intensive case management model. Additionally, the report showed that WPC clients received statistically significant better care in follow-up after hospitalization for mental illness, as well as initiation and engagement in treatment for alcohol and other drug dependence, when compared to a control group of Medi-Cal enrollees with similar demographic, health, and service utilization patterns.
Better Health Outcomes
The evaluation shows a complicated yet optimistic picture of health outcomes as a result of WPC. Compared to a control group, WPC clients had significantly greater reductions in Emergency Department (ED) use (19% vs. 8%) and all-cause readmissions (16% vs. 2%) between their first and second years of enrollment. ED use and all-cause readmissions increased immediately after enrollment in the program, likely because pilots identified clients based on high rates of utilization, and those high rates continued to trend upward until the program had time to take effect (See Figure 4). While hospitalization rates decreased more in the control group, WPC clients were less likely to ever experience an ED visit or hospitalization during enrollment in the program. Of the six pilots who tracked self-reported health, the percent of beneficiaries reporting “Excellent” or “Very Good” increased for emotional health (15% to 22%) and almost threefold for overall health (8% to 22%). Finally, pilots reported improved rates of control in blood pressure and HbA1c for WPC clients.
Next Steps
With California’s 1115 waiver slated to end this December, and the state’s newest initiative, CalAIM, delayed indefinitely, the future of WPC is uncertain. The interim evaluation demonstrates the critical role of WPC in caring for individuals with complex health and social needs, particularly by strengthening care coordination and improving care processes and outcomes. COVID-19 has further highlighted the value of WPC by leveraging pilot infrastructure and services to address the pandemic and reach those most vulnerable to the virus. Shuttering the program this year, without a clear transition plan, may mean losing the gains that pilots have worked so hard to achieve and, worse still, eroding the trust of clients who look to WPC for support. Extending funding for WPC through 2021 will be critical for pilots to continue to build on successes to date, support counties’ COVID-19 emergency response, and improve care for California’s most vulnerable communities.