Finding Support and Shelter on the Road to Better Health

October 25, 2019 |  By Transform Health 

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Woman pushing a man in a wheelchair
Figure 1: Sacramento community health worker Jamie Kaihe-Valles meets client Noel Tyler at a local shelter (Photograph by Brian Rinker)

Pathways to Health + Home (Pathways), is one of Transform Health’s projects led in partnership by a support team inclusive of consulting firms, community-based organizations, hospital systems, health insurance plans, clinics, and the City of Sacramento. It is a health system transformation effort implemented by Transform Health that was recently featured in Health Affairs’ “Leading to Health” series on health transformation efforts across the US. The goal of this Robert Wood Johnson Foundation funded series is to take a deeper dive into what it means to develop a culture of health, inclusive of whole-person care, health disparities, and engaging patients where they are.

Pathways is a health care and housing pilot program under California’s Whole Person Care (WPC) umbrella and led by the City of Sacramento. WPC is a statewide demonstration project funded by an 1115 Medicaid waiver, which supports care coordination between housing, health, and social services using a patient-centered approach. Pathways is a little bit different than the other WPC demonstrations because the City of Sacramento is taking the lead on implementation where, in most examples, Medicaid programs are driven by county-based efforts. To date, Pathways has partnered with nearly 30 Sacramento-based organizations – including hospitals, health plans, Federally Qualified Health Centers (FQHCs) and community based organizations – and has served 1,557 people experiencing homelessness between November 2017 and September 2019, of which 415 have been housed

The Health Affairs article highlights the story of how implementing Pathways, while challenging, is changing the health care access landscape for people experiencing homelessness and facilitating a supportive path towards permanent housing. By applying a collective impact approach to health system transformation and funding infrastructure that supports care coordination these 29 organizations now convene around a central mission inclusive of a newly developed shared communication platform referred to as, the “shared care plan,” allowing for care coordination workflows.

Highlighted here are a few of the key lessons our program has learned to date:

  1. Leveraging experience and relationships with the right stakeholders, at the right time
    • WPC eligible populations must be high-risk patients who are also high utilizers of health care and/or emergency services. In Sacramento, the City focuses on people experiencing with the intention of stabilizing their health, connecting them to housing services, and enrolling them in Medicaid (Medi-Cal in California). To manage the pilot as a municipality without a county Health Department, the City engaged Transform Health to launch Pathways. With support from Intrepid Ascent, Desert Vista Consulting and Health Management Associates, Transform Health built out workflows to implement the pilot, engaged community stakeholders for their input during development, and created and supported the infrastructure critical for the pilot’s success.
    • Local stakeholders played an indispensable role in getting the pilot off the ground. Sacramento Covered is a local non-profit that provides enrollment and navigation services and served as the Pathways eligibility and enrollment entity. The City partnered with Sacramento Covered, Dignity Health, and the Sacramento Police Department IMPACT team to create simple referral pathways for individuals who meet program criteria. Quick warm hand-offs ensured eligible populations were directed to needed services with both health care and housing entities.
  1. Relationship building through cross-sector communication
    • Pathways brings health care providers, housing providers and social service entities together in new ways through a secure data sharing platform. This allows service providers to provide care coordination in real time. The results are streamlined services provided to enrollees in coordinated and seamless ways.
    • Pathways also established Care Teams for each enrollee. The Care Teams include outreach community health workers, housing navigators, and primary care staff, who conduct weekly huddles. In a huddle, each Care Team goes through their enrollment list and coordinates next steps across the team. These strategies help break down silos while ensuring that enrollees receive coordinated stabilizing services without duplication of effort. The contracted service partners agree that these partnerships will be one of the lasting legacies of Pathways.
  1. Sharing data is central to the pilot
    • Because of privacy laws, outreach, health, and housing providers are not able to share patient information or data with each other unless they have a formal written agreement in place. Early in the planning stage, it was clear that sharing data would be critical for the pilot’s success. Allowing health systems and plans to share enrollee information with outreach, health, and housing providers reduces costs by avoiding uncoordinated, repetitive efforts. While no easy feat, Data Sharing Agreements (DSAs) were key for both coordinating care and reporting outcomes. It is not standard practice for large hospital systems to share data with smaller community-based organizations, yet in the Pathways demonstration, it was critical. Trust-building and partner engagement were essential components for laying out expectations and building the pilot.
    • To date, Pathways has successfully executed DSA’s with 25 organizations across Sacramento, including major hospital systems, health plans, FQHCs and community-based organizations.

To read the story of Sacramento’s Whole Person Care pilot, known as Pathways to Health + Home click here.

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