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Integrating California’s Safety Net

Dr. Annette Gardner, PhD of UCSF recently looked at 5 different California safety net systems to determine their progresses in integration leading up to 2014. At a briefing in Oakland on December 13, 2011, representatives from the 5 county systems came together to review the findings and share, in person, successes and challenges within their counties. Dr. Gardner also presented findings from her study.

Annette selected the following five disparate counties that are very involved in implementing services and systems to create seamless health care safety nets for her research study. Counties vary based on type of delivery system, community, participation in the 2005 Coverage Initiatives, and geographic location.

  • San Mateo: A County Organized Health System (COHS) county in the Bay Area that received federal matching funds under the 2005 waiver to create a Coverage Initiative;
  • San Diego: A Payor county in Southern California that also participated in the 2005 waiver;
  • Contra Costa: A Provider and Local Initiative county in the Bay Area that participated in the 2005 waiver;
  • Humboldt: A CMSP county in the Rural North; and
  • San Joaquin: Also a Provider and Local Initiative county located in the Central Valley.

Representatives from each county shared successes and challenges they have faced in terms of integrating their delivery systems, in addition to the resources they would need to facilitate the process. Below are the Meeting summaries from each county.

San Mateo

In San Mateo, the hospital, clinics and Medi-Cal plan all work together. Their only non-county clinic is Ravenswood. San Mateo has had success collocating their behavioral health and primary care. They emphasized that the existence of a mostly public safety net does not necessarily guarantee integration. The disparities between the county’s rural and urban regions have posed challenges and the high FQHC and Long-Term Care reimbursements have hindered their ability to care for their patients. In addition, the County has faced difficulty in responding to the rapidly changing needs of the population. Representatives from San Mateo mentioned that they could use more technical expertise, especially in terms of bolstering their IT systems to meet the needs of the County.

San Diego

Because San Diego is a Payor county and does not provide services, they are able to facilitate services and ensure alignment and integration among providers. It also helps that the Council of Community  Clinics, a clinic consortium, provides a unified voice for all community health centers. San Diego prefers to focus on service integration, in which they ensure coordinated care for the patient, rather than organizational integration. The County has the highest number of clinics per capita than any other county, but there are issues with data sharing. Reimbursement levels for public programs are low and there is a lack of responsibility for the undocumented and uninsured.  San Diego also has the world’s busiest border, and must care for those who don’t reside in the country. Representatives indicated that there should be more of an alignment between federal and state policy (for example, so that ACOs do not compete with each other) and they could use more expertise and financial resources.

Contra Costa

Entities in Contra Costa have a long history of working together and all entities have a common mission. In addition, all of the health care entities are located in one agency. Integration is also facilitated through formal contractual relationships through the health plan, which contracts with community clinics for Medi-Cal and the undocumented. The county has had a lot of success partnering with the multiple non-county clinics. Currently, the County lacks effective Electronic Medical Records. Their system, “Epic,” will be up and running by July 1, 2012. The County has experienced a 40% reduction in clinic contribution and faces competition for funding among the health system, Sherriff and district attorney. Representatives from Contra Costa support the adoption of a Basic Health Plan so that they can transition those enrolled in the local health plan. They would also support including FQHCs in the BHP network.


Humboldt is a payor county and a part of the County Medical Services Program (a program for California’s rural counties). Representatives from Humboldt County identified geographic isolation as one of the County’s biggest advantages and disadvantages. It has caused Humboldt to become more self-sufficient and enable them to create relationships that are generally tough to create in urban counties since different entities must cooperate in order to survive. They have also invested in strong telemedicine and a variety of other forms of communication.

San Joaquin

Representatives from San Joaquin prided themselves on strong County leadership and a willingness to work together for system change. The County has a strong infrastructure with a common mission and a long history of working together. They have managed to obtain a number of grants based on this strong collaboration. The County, however, lacks sufficient specialty care services and are burdened by state requirements for the county (such as the shifting of prison inmates). San Joaquin also has a lack of strong IT infrastructure and ePrescribing. They are leading the state in numbers of foreclosures and are constantly responding to a series of cuts. They still have a lot of work to do in integrating mental health and could use technical assistance and “change management.”

We look forward to continuing the discussion on Safety Net Integration at our Issue Workgroup on Wednesday. The workgroup will be hosted in both Los Angeles and Sacramento (the two locations will connect via teleconferencing). Dr. Gardner will be present to share her findings with participants. For more information, e-mail me at ashley@itup.org. Annette’s research findings will be publicly available in the coming months.