Care Integration for Patients with Complex Needs

Health systems and payers face challenges addressing the needs of patients with complex behavioral and social needs, many of them with expensive medical conditions driven by untreated mental illness or substance use disorder. Providing appropriate care for these patients is difficult for many reasons: the challenge of identifying and engaging them, navigating fragmented financing streams, integrating different disciplines with diverse cultures, and the availability of good data to demonstrate the return on investment and the case for sustainable funding.

To address these challenges and build on the emerging evidence from integrated models across the United States, CHCF provided planning and implementation grants to teams of Medi-Cal health plans, county health systems, and community health centers to establish new integrated care programs. Each team is building a program and determining a financially sustainable reimbursement model. The teams are also ensuring that patients have access to medication-assisted treatment for addiction as well as basic behavioral health services.

The Camden Coalition of Health Care Providers, known nationally for innovation in the field of integrated team care for patients with complex needs, is providing technical assistance and training support for the teams. The Urban Institute is conducting an evaluation of the project.

The selected partnerships, awarded through an RFP process in late 2015, are each listed by the lead agency with partner(s):

  • El Dorado Community Health Centers and California Health & Wellness
  • Family Health Centers of San Diego and Community Health Group
  • Health Plan of San Joaquin, Community Medical Centers, and San Joaquin General Hospital / San Joaquin County Clinics
  • Harbor-UCLA Medical Center working with the Los Angeles County Department of Health Services
  • Los Angeles County-USC Medical Center working with the Los Angeles County Department of Health Services
  • Martin Luther King, Jr. Outpatient Center working with the Los Angeles County Department of Health Services
  • Partnership HealthPlan of California, Hill Country Health & Wellness Center, and Mendocino Community Health Clinic
  • San Ysidro Health Center and Community Health Group

In the video below, Brian Akers and Katharine Royer present the model developed by the Camden Coalition of Healthcare Providers.