When Kaiser Permanente began implementing California’s Medi-Cal Doula benefit, much of the work involved familiar implementation challenges. There were contracts to develop, billing processes to navigate, operational workflows to establish, and a new provider group to integrate. But as the work unfolded, it became clear that contracts and workflows were only part of the problem. Successfully integrating Doulas also raised questions about relationships, organizational culture, community infrastructure, and trust.
That process was shared at a recent California Improvement Network (CIN) partner convening, where health plans, providers, community-based organizations, and public agencies came together to learn from one another’s implementation experiences and approaches to improving care.
During the convening, Kaiser Permanente’s Esme Cullen, MD, Chief Health Equity Officer for National Medicaid and State Programs, and Joseph De Los Santos, California Health Equity Strategy Lead, shared what the organization has learned while implementing the benefit.
Their experience points to a broader question for many organizations: What happens when implementing a new model of care reveals questions that extend beyond the program itself?
For Kaiser Permanente, understanding those challenges started with listening to the people closest to the work. Through a nationwide scan, they gathered input from clinicians, Doulas, and members to better understand where potential barriers and opportunities existed. As the work continued, engagement with Doulas and community partners surfaced challenges, from navigating unfamiliar contracting and billing systems to building awareness while providing culturally responsive care. Looking across the diverse perspectives helped Kaiser Permanente identify where additional attention and support were needed.
“Asking yourself as an organization, ‘Where are we today?’ and doing a temperature check by gathering data is always the right call.”
Esme Cullen, MD
The assessment also made clear that integrating Doulas would require coordination well beyond maternal health teams. Teams from contracting, reimbursement, clinical practice, quality improvement, operations, health equity, and regulatory requirements became increasingly interconnected. As planning progressed, many operational issues proved to be less about process and more about building relationships, fostering communication, and aligning organizational culture
In response, Kaiser Permanente brought together leaders from health equity, quality, operations, contracting, Medi-Cal contract management/regulatory, policy, care delivery, and local engagement to drive solutions collectively. Successfully integrating a new benefit required collaboration across the organization, not ownership by a single department.
“We thought there might be opportunities to bring more resources together internally to better support our birthing people and our Doulas.”
Joseph De Los Santos
Listening also shaped how Kaiser Permanente thought about measuring success. Utilization alone couldn’t answer one of the team’s biggest questions: how much demand existed for Doula services? If members don’t know the benefit exists and don’t understand what a Doula does, low utilization may reflect limited awareness rather than limited demand. That realization reinforced the importance of building awareness among members through trusted community partners.
The conversation at the CIN convening expanded beyond the Doula benefit to broader questions about integrating community providers into health care systems. Participants drew parallels between community health workers and Doulas, both of which have had to navigate health care systems built around contracting, documentation, billing, and standardized processes. They raised questions about the administrative burden placed on community-based providers and how organizations can provide support without over-medicalizing or institutionalizing community-rooted work.
One participant offered an example from a Native community, where traditional childbirth support may be provided without payment. Introducing a reimbursable benefit into that context raises a larger question for health system leaders: how to build structures that support and reimburse community-rooted practices while respecting the cultural traditions and relationships that shape them.
These questions did not come with simple answers. Cullen and De Los Santos spoke openly about what remains difficult, from understanding demand to strengthening the infrastructure needed to support Doulas. Rather than presenting a finished playbook, they described an effort that continues to evolve alongside the people and communities it serves.
“No single organization can address this need alone. We’re committed to doing our part and working with others who share our goal, because that’s how real progress happens.”
Esme Cullen, MD
The conversation may have centered on California’s Medi-Cal Doula benefit, but the implementation questions it raised extend well beyond maternal health. Organizations across California are introducing new workforces, partnerships, and models of care. Many will discover that the hardest part isn’t launching the program but recognizing that the real implementation challenges may be different from the ones they were expecting.
One of the most useful questions to carry into any major change effort may be the simplest: Are we solving the right problem? As Kaiser Permanente’s experience suggests, the answer may be found by listening to the people closest to the work.
The California Improvement Network is a project of the California Health Care Foundation and is managed by Healthforce Center at UCSF.
