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Jump to All Downloads & LinksThis 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.
Authors & Contributors
Michael Parchman, MD, MPH
Michael Parchman is a senior investigator at the Center for Accelerating Care Transformation at Kaiser Permanente Washington Health Research Institute.
Kelsey Stefanik-Guizlo, MPH
Kelsey Stefanik-Guizlo is a collaborative scientist at the Center for Accelerating Care Transformation at Kaiser Permanente Washington Health Research Institute.
Avni Shah, MD
Avni Shah is founder and president of Vayu Health.
Alan Glaseroff, MD
Alan Glaseroff is an advisor to Vayu Health; the cofounder and former codirector at Stanford Coordinated Care; and an adjunct professor at the Clinical Excellence Research Center at Stanford School of Medicine.
Erika Holden, BA
Erika Holden is project manager at the Center for Accelerating Care Transformation at Kaiser Permanente Washington Health Research Institute.
John Bertko, FSA
John Bertko is an advisor to Vayu Health and a retired chief actuary at Covered California.
Ramiro Zúñiga, MD, MBA
Ramiro Zúñiga is the vice president and medical director of Medi-Cal at Health Net.
