Santa Cruz County

Agenda Item
Accepted and filed
Oct 20, 2020 9:00 AM

Accept and file a mid-year report on the Whole Person Care - Cruz to Health pilot program, and direct the Health Services Agency to return no later than June 2021 with the next update, as recommended by the Director of Health Services


Department:Health Services Agency: Behavioral Health DivisionSponsors:Director of Health Services Agency Mimi Hall
Category:HSA BH - Board LetterProjects:Master Calendar
Functions:Health & Human Services


  1. Board Memo

Board Letter

Recommended Actions:

1.     Accept and file a mid-year report of calendar year 2020 for the Whole Person Care - Cruz to Health pilot; and


2.              Direct the Health Services Agency to return no later than June 2021 with the next Whole Person Care - Cruz to Health update.


Executive Summary

The Health Services Agency (HSA) coordinates the Whole Person Care - Cruz to Health (WPC-C2H) demonstration pilot through a grant administered by the California Department of Health Care Services (DHCS), together with matching funds from Mental Health Services Act and behavioral health realignment. HSA has submitted to DHCS: 1) the required confidential data report for 2020 Quarters 1 and 2; and 2) the 2020 Calendar Mid-Year Report. The 2020 mid-year data demonstrates progress achievements related to improving services, improved coordination of efforts, and data-sharing.



DHCS established its WPC-C2H grant program for five calendar years from January 2016 through December 2020. In 2017, DHCS awarded HSA a WPC grant with a three and a half-year term of July 2017 through December 2020. At the mid-year of DHCS Program Year (PY) 5, 2020, HSA’s WPC pilot had completed 36 months, as shown here:


Table: Schedule of DHCS’s WPC Program Five Calendar Years - 2016 to 2020



Whole Person Care

Year 1

Year 2

Year 3

Year 4

Year 5



HSA Quarters Completed








Quarter 1









Quarter 2









Quarter 3









Quarter 4









HSA’s pilot, Whole Person Care - ‘Cruz to Health’ (WPC-C2H) is designed to improve care coordination and health outcomes for up to 625 unduplicated adult Medi-Cal beneficiaries in Santa Cruz County for its three and a half-year period ending December 2020, using innovative interventions and an improved data sharing and care coordination infrastructure. Target participants are those who have a mental health diagnosis and/or a Substance Use Disorder, co-occurring chronic health conditions, repeated and avoidable medical and/or psychiatric hospitalizations, involvement with the criminal justice system, and/or are experiencing homelessness or are at-risk for homelessness.


On June 16, 2020, the Board accepted HSA’s report for the 2019 annual report and directed HSA to return to the Board with a next report no later than October 2020. In early September 2020, HSA submitted to DHCS confidential data reports for Quarters 1 and 2, and a mid-year narrative report for mid-year Calendar Year 2020, Quarters 1, 2. The highlights of aggregate data and narrative for mid-year 2020 are now presented here.



The following diagram highlights the WPC-C2H framework, where two “arms” exist: Systems Change, and Direct Services. The sections below highlight achievements made in each of the “arms”, as well as efforts around Process Improvements.



Process Improvements

In alignment with the innovations and Plan-Do-Study-Act (PDSA) underlying focus of WPC-C2H, the pilot sponsored Cohort 2 of the County’s PRocess IMprovement Onward (PRIMO!) Lean Six Sigma Green Belt Training. Of the 35 participants from HSA, the Human Services Department (HSD), and five community partner agencies who finished the training in 2019, by the end of June 2020, 15 participants successfully completed their projects and are now Lean Six Sigma Green Belt certified.


Direct Services

·              64 unduplicated enrollees received Peer Support Coaching services;


·              100 unduplicated enrollees received Clinics-based Case Management services;


·         In response to the COVID-19 pandemic, WPC-C2H staff and contracted vendors adapted swiftly to the local and state orders to shelter-in-place. Support and guidance were provided to direct service staff to work at home, continuing to support enrollees through telephonic visits and outdoor, socially distanced, or contactless engagement; and


·         The evidence-based group wellness intervention, Integrated Illness Management and Recovery (I-IMR) was not implemented in 2020 due to COVID-19 prevention measures. However, an I-IMR facilitator training was conducted in January 2020. This training was the first of its kind for this intervention – it was led by county staff who were trained as master trainers by the intervention developers, further demonstrating the ability to scale and sustain I-IMR in the Santa Cruz community.


Direct Services: Housing Supports

·              9 unduplicated enrollees were reported being housed due to direct supports from WPC-C2H;


·              94 unduplicated enrollees received Housing Navigation services;


·              65 unduplicated enrollees utilized Housing Supports funds, in the form of monetary housing deposits, and/or first month’s rent, and/or housing application fees; and


·              111 unduplicated enrollees utilized Tenancy Supports funds, in the form of equipment, goods, and services to support participants moving into and stabilizing in new housing situations, representing an increase in utilization as clients sheltered-in-place and required additional cleaning supplies and resources to stay at home.


Systems Change: Data Sharing Infrastructure and Care Coordination


·         Together We Care

The development and implementation of a care coordination platform continued to progress. The build process for Together We Care (TWC) within the Santa Cruz Health Information Exchange (SCHIE) began with the vendor ActMD (now ActivateCare) and now includes UniteUs, the social services referral program vendor that will be embedded in TWC. The platform with both services will launch by the end of 2020 to serve WPC-C2H enrollees.


The TWC Steering Committee completed a rigorous and complex vetting process to ultimately choose UniteUs as our Community Referral and Directory System. WPC-C2H has begun actively preparing for community engagement work, partner collaboration, and use-case trainings. The planning and engagement of these efforts takes place in the TWC Steering Committee meetings and User Group meetings which each take place two times a month. A roll out event for partners is planned for later this year. TWC continues to host regular standing meetings with End Users (operational staff), Users (managers and leadership), and the Steering Committee (leaders and policymakers) and continues to address critical implementation and rollout activities. WPC-C2H worked closely with partners at Santa Cruz Health Information Organization (SCHIO) and ActivateCare to address data concerns, enhance clinician interfaces, and develop processes for reporting that support all our complex coordinated care communities.


·         Notifications of Emergency Department (ED) use of WPC-C2H enrollees

Notifications of ED use is now fed into the Health Information Exchange (HIE) from local EDs, which then flow to the County Clinic’s electronic health record. HIE notifications of ED use to the County’s EHR allows active notification of care team members of enrollees’ admission and discharge to local emergency departments. This valuable integration improves how enrollees are coordinated during inpatient stays and upon discharge for a more seamless flow of services by allowing care team members to receive notice more expediently of client ED admission.


·         Program Enrollment Registry and Data Quality Monitoring Tool

WPC-C2H consultants, Intrepid Ascent, conducted exploratory interviews to determine the needs of a program enrollment registry for Santa Cruz County, which could support improved client care across multiple agencies. The team began building use cases and identified ways to work within the County and with external partners to develop this registry by the end of PY5. Consultants from Intrepid Ascent also began developing a design for a data quality monitoring tool, which included determining what the data sources require for data quality monitoring and best way to validate them in relation to supporting improved care coordination of complex WPC-C2H enrollees. Work will continue in the second half of the program year.


·         ANSA System Improvements 

The ANSA (Adult Needs and Strengths Assessment) team completed an in-depth review and revision of the algorithm used to match Behavioral Health clients with the ideal level of care and track their progress over time. A small group of local clinicians are testing the use of the algorithm to inform any needed changes before expanding use.


In collaboration with CDR (Community Data Roundtable) the WPC-C2H team is working to roll-out client level reports to users of ANSA. This included training on how clinicians access the reports via the CDR-supported portal “DataPool” as well as guidance for how these reports can be used interactively in client sessions to optimize client engagement in decision making and prioritization of their care. HIP (Health Improvement Project) project managers assisted progress toward overcoming challenges in the process of data extraction, via the County Behavioral Health electronic health record, into the DataPool portal so that clinicians have a seamless experience when they interact with the system. ANSA training sessions are planned for all users of the instruments. Lastly, there is internal progress on optimizing availability of resources ANSA use, focused upon the imminent launch of a new County website, which includes updated forms and client outreach options.


Key Reporting Information

On September 9, 2020, HSA submitted to the State its DHCS Program Year 5 Mid-Year Report, for 2020 Quarters 1 and 2, highlights of which are provided below. The 2020 Enrollment and Utilization Reports of confidential data were securely submitted to DHCS on April 30, 2020 for Quarter 1 and July 31, 2020 for Quarter 2.


At the end of mid-year 2020 (as of June 30, 2020), 466 WPC-C2H individuals were enrolled. Since the beginning of the pilot, there have been 556 total unduplicated enrolled individuals (out of the 625-target unduplicated enrollment for the duration of the pilot). As aggregate data, target population characteristics are expressed as duplicated numbers, as each of the 466 enrollees pertain to more than one of the following categories:


·              48 unduplicated new enrollees were added to WPC-C2H; and


·         Forty-two percent (42%) of the program’s mid-year 2020 enrollees report as residing within the City of Santa Cruz, 19% report as residing in Watsonville, and the remaining 39% report residing in other cities.


Upcoming Report: HSA’s Next Update - 2020 Annual Report

HSA’s next report to the Board for WPC-C2H, will span 2020 Quarters 1, 2, 3, and 4, January through December. This upcoming report will include discussion of the following accomplishments:


·              Updated status on the 1115 Waiver Extension, which includes a one-year extension of WPC, as requested by DHCS to the Centers for Medicare and Medicaid Services (CMS);


·              Completion of three lessons learned reports focused on – Case Management, Housing Supports and Data Sharing;


·              Continue the referral and enrollment process to identify individuals who qualify for and would benefit from WPC-C2H services;


·              Continue the enrollment consent process for program clients using documents and verbal consent approved by County Counsel;


·              Continue to improve and ensure maximum utilization of services as described in the approved grant agreement, with plans for sustainability where possible, including Clinics-based Case Management and Integrated Illness Management and Recovery (I-IMR) skills building classes as allowed by the County Health Officer’s Shelter-In-Place orders on gatherings;


·              Continue to report enrollment, utilization, and health outcome data to DHCS on a quarterly basis;


·              Continue to collaborate with SCHIO and community partners to identify data-sharing needs in the community and develop the care coordination and case management platform to include the social services referral program within “Together We Care”, for WPC-C2H enrollees; and


·              Continue to hold bi-monthly WPC-C2H Advisory Council meetings, as well as separate and ongoing workgroup and leadership meetings.


Strategic Plan Elements

The WPC-C2H pilot is designed to improve integration of behavioral health and health care services, care coordination, and health outcomes for adult Medi-Cal beneficiaries in Santa Cruz County, as follows:


·              1.B (Comprehensive Health & Safety: Community Support) - WPC-C2H provides access to basic comprehensive health and safety support through integrated health care and social services.


·              1.D (Comprehensive Health & Safety: Behavioral Health) - WPC-C2H supports residents and lessens community impacts through increased access to integrated mental health, substance use disorder, and health care services.


·              2.D (Attainable Housing: Homelessness) - WPC-C2H expands coordination of services that seek to reduce homelessness and increase housing stability.

Meeting History

Oct 20, 2020 9:00 AM Video Board of Supervisors Regular Meeting

Return June 2021

MOVER:John Leopold, First District Supervisor
SECONDER:Ryan Coonerty, Third District Supervisor
AYES:John Leopold, Zach Friend, Ryan Coonerty, Greg Caput, Bruce McPherson