This report looks at a partnership between a nonprofit organization, a Medi-Cal managed care plan, and a Federally Qualified Health Center that sought to address complex patient needs, particularly in the context of diabetes care. Specifically, the case study outlines a program among Vayu Health, a nonprofit in California; Health Net, a Medicaid managed care health plan; and Ampla Health, a Federally Qualified Health Center.

While this case study and program focuses on Medi-Cal enrollees with diabetes, there are several implications for health care organizations and policymakers looking to improve care for other Medi-Cal patients with complex health needs, such as within the CalAIM initiative.

Key Takeaways

Key takeaways for health care organizations and policymakers include:

• Designing a comprehensive care team. The program employed a dedicated care team comprising registered nurses, community health workers, certified diabetes educators, and behavioral health counselors who served Medi-Cal patients. The program offered high-touch patient interactions and trauma-informed care, and addressed the entire spectrum of a patient’s medical, behavioral, and social health needs.
• Health improvement follows patient-centered care. Following enrollment in the program, Medi-Cal enrollees with diabetes experienced significant improvements in blood sugar levels known as HbA1c values, indicating better diabetes control. These improvements can be attributed to several factors, including building trust with care teams, focusing on patient-identified goals, adopting a multidisciplinary team approach, reducing access barriers, providing additional diabetes support, and offering proactive care coordination.
• Advancing health equity. The program helped reduce disparities in diabetes control, particularly between Latino/x and non-Latino/x White participants. This achievement is credited to both structural elements and relationship-building efforts within the program.

About the Authors

Michael Parchman, MD, MPH
Senior investigator, Center for Accelerating Care Transformation, Kaiser Permanente Washington Health Research Institute

Kelsey Stefanik-Guizlo, MPH
Collaborative scientist, Center for Accelerating Care Transformation, Kaiser Permanente Washington Health Research Institute

Avni Shah, MD
Founder and president, Vayu Health

Alan Glaseroff, MD
Advisor to Vayu Health; cofounder and former codirector, Stanford Coordinated Care; adjunct professor, Clinical Excellence Research Center, Stanford School of Medicine

Erika Holden, BA
Project manager, Center for Accelerating Care Transformation, Kaiser Permanente Washington Health Research Institute

John Bertko, FSA
Advisor to Vayu Health, retired chief actuary at Covered California

Ramiro Zúñiga, MD, MBA
Vice president and medical director, Medi-Cal at Health Net