Behavioral and Physical Health Service Integration in California’s Safety Net: Six County Profiles

July 7, 2015

In the wake of the Affordable Care Act’s implementation, counties throughout the State continue to strive to meet the expectations set by the new law to better serve Medi-Cal beneficiaries. This includes providing more coordinated and integrated care that leads to improved service access and quality, better health outcomes, and reduced health costs. Roughly 16% of California adults have a mental illness, yet only around half receive treatment; 9% of the state’s residents have an SUD, and one in ten in that group receives treatment.[1] Therefore, providing better access to treatment that is integrated in a whole-person approach to care is especially important for newly insured populations that may disproportionately suffer with mental illness and/or co-occurring conditions (such as people struggling with homelessness or involved in the criminal justice system).

While all counties have responsibility for specialty mental health services, and most operate Drug Medi-Cal programs, each county is unique in how it administers and provides safety net physical and behavioral health services. This report details how six innovative counties have integrated behavioral and physical health services to better meet the needs of their residents. The profiled counties include San Mateo, Riverside, Los Angeles, San Diego, Shasta, and Santa Cruz Counties. All counties have some mix of directly operated and contracted specialty mental health service providers, yet the counties differ in whether or not they have directly operated medical delivery systems, the type of managed care models used, and how their managed care plans organize their mild to moderate mental health benefits. Moreover, each county has key elements of success that set them apart from one another.

San Mateo. The very strong relationship between the San Mateo County delivery systems and the local Medi-Cal managed care plan, Health Plan of San Mateo, has spurred many of the advances in San Mateo County. Moreover, San Mateo has a COHS model of Medi-Cal managed care with one local health plan and strong county-operated physical and mental health delivery systems that enable collaboration with fewer and more consolidated administrative entities. The close relationship between the delivery systems includes advanced data sharing capabilities that greatly promote integration, unified treatment planning, and evaluation of clinical outcomes and the overall cost of care across a broad range of Medi-Cal benefits. San Mateo participants also attributed the success of their pilots and innovations to the financial support and the strong and innovative leadership of both the County and HSPM.

Riverside. Riverside County’s integration efforts are a product of strong leadership of both County physical and behavioral health administrators and the local initiative Medi-Cal managed care plan, Inland Empire Health Plan (IEHP). Riverside is able to leverage its large County-operated heath care delivery systems in its integration efforts by co-locating staff to create interdisciplinary teams in both primary care and mental health clinics. Moreover, IEHP demonstrates unusual capacity to organize and deliver Medi-Cal behavioral health services by directly contracting its provider network, which includes County facilities, and adding wrap-around services not included in the Medi-Cal benefits package. IEHP additionally commits financial resources to integrating and co-locating services in both primary care and behavioral health facilities, as well as across administrative entities.

Los Angeles. Los Angeles County benefits from both strong financial resources and large County-operated and private safety net provider networks, as well as a commitment among County health administrators and the local initiative health plan, L.A. Care Health Plan, to innovative service integration models. In fact, Los Angeles County’s integration efforts extend beyond physical and behavioral health services to include social services, housing, and public safety. County administrators’ consensus to move toward integration has driven their efforts to co-locate and integrate services across its large networks of County-operated facilities. Moreover, the county’s strong community clinic network, the Community Clinic Association of Los Angeles County, contributes meaningfully to these efforts by participating in the creation of Health Neighborhoods and co-locating primary care practitioners in County mental health facilities where possible. While the commitment to and the resources for service integration are substantial, the major task ahead is to bring these efforts to scale across the very large delivery systems that serve the nation’s most populous county and its enormous diversity of residents.

San Diego. San Diego stakeholders rely on a strong planning body, the Healthy San Diego Behavioral Health Workgroup, in which health plans, County representatives, hospitals, advocates, and community clinics meet to identify challenges and responsibilities related to behavioral health services. The role of this planning space is particularly important for San Diego stakeholders because the county’s geographic managed care model of Medi-Cal managed care involves five plans, which can make coordination efforts a heavier lift with the greater number of administrative entities. Moreover, the County has a smaller directly operated health care delivery system for its size, which also amplifies the challenge of coordinating efforts across a larger number of providers.

Another central component of successful integration efforts in San Diego County was the robust partnership between the County and the community clinics. These stakeholders created regional triads of administrators of physical health, behavioral health, and SUD service facilities to align their services and create interdisciplinary learning communities. Clinics and the County also actively collaborate to skillfully transition clients moving from specialty mental heath services to those provided in community clinics.

Shasta. Shasta has the advantages of very strong collaborative relationships among its stakeholders. The Shasta Health Assessment and Redesign Collaborative serves as a central planning workgroup, and the reflex to coordinate and integrate services is strong in this region of California. At the same time, Shasta has fewer resources than many of the larger counties, both with regard to County financing and its provider networks. County administrators and Shasta’s provider networks have been able to pioneer integration efforts in this environment by creating innovative contracts and financing arrangements. These partnerships have integrated services through co-locations that allow for the creation of interdisciplinary care teams. Further, a strong COHS-model Medi-Cal managed care plan, Partnership Health Plan, extends resources and technical expertise to aid provider recruitment and care coordination. While Shasta’s stakeholders continually struggle with provider supply, all stakeholders are committed to better use of technology to respond to this increasingly pressing issue as they integrate Medi-Cal services.

Santa Cruz. Santa Cruz County’s efforts to integrate have revolved around the special needs of their communities and the resources available to them. Santa Cruz stakeholders have come together across an unusually broad range of stakeholders that spanned across physical health, behavioral health, social services, housing and criminal justice to address the needs of people struggling with homelessness. Moreover, the lack of large public health care delivery systems motivated Santa Cruz stakeholders to collaborate and to pool or share resources. The City of Santa Cruz partnered with the County to provide funding for innovative interdisciplinary programs that relied on many non-profit service providers to assist some of the county’s most vulnerable residents. Perhaps most strikingly, the broad coalition of service providers effectively tackled a complex social problem and made a tangible impact on residents’ overall quality of life.

In summary, stakeholders in every county communicated the critical contributions of durable local leadership and an interdisciplinary planning workgroup, formal or informal. Almost all counties’ stakeholder groups also identified the importance of either a funding source or flexibility with funding to put their ideas into practice. On the provider level, many of the participants reported the necessity of bridging provider cultures in the process of building interdisciplinary teams.

Virtually all participants cited the importance of the expanded Medi-Cal mental health and SUD benefits that were newly implemented in 2014. Many stakeholders expressed dissatisfaction with the division of responsibilities between Medi-Cal managed care plans and county specialty mental health plans for mental health benefits. However, the need for these entities and provider networks to collaborate to develop MOUs to navigate the bifurcation of responsibility was important to building agreements and stronger communication across entities.

Data exchange between providers and delivery systems remains one of the more primitive capabilities that the administrators and providers were able to use, but it was cited universally as very pivotal to integration efforts. In fact, expanding the reach of telemedicine and e-medicine was a central piece of some counties’ integration efforts.

[1] California Mental Health and Substance Use System Needs Assessment. 2012. Technical Assistance Collaborative. Available at: %20Assessment%203%201%2012.pdf

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County Behavioral Health Profiles