“Living well" would be an accurate way to describe the experiences of tourists who visit San Diego, often for its miles of white-sand beaches and amazing weather. But behind the scenes, too, city healthcare leaders have been working hard on their own version of living well.
Indeed, a strategic vision known as “Live Well San Diego”—the city’s 10-year plan to focus on building better health, living safely and thriving—has provided a foundational base for how healthcare in San Diego should be imagined. Essentially, the strategy aligns the efforts of individuals, organizations and government to help all 3.3 million San Diego County residents live well, the region’s health officials say.As Nick Yphantides, M.D., the chief medical officer for San Diego County’s medical care services division, puts it in a recent sit-down interview with Healthcare Informatics, “It’s not just about healthcare delivery, but it’s about the context and environment in which that delivery occurs.” Expanding on that, Yphantides notes that the key components for Live Well San Diego are indeed health, safety, and thriving, and within these larger buckets are critical care considerations such as: economic development, vitality, social economic factors, social determinants of health, preparedness and security, and finally, being proactive in one’s care.
So far, through the Live Well San Diego initiative, the city has created more than 8,000 healthcare jobs over a five-year span and more than 1.2 million square feet of additional hospital space, according to a 2017 report on Southern California’s growing healthcare industry.
From here, the attention has turned to improving the data sharing infrastructure in the city, a significant patient care challenge that is not unique to San Diego, but nonetheless critical to the evolution of any healthcare market that is progressing toward a value-based care future. To this end, toward the end of 2016, ConnectWellSD, a county-wide effort to put Live Well San Diego into action, was launched with the aim to improve access to county health services, serving as a “one-stop-shop” for customer navigation. Officials note that while still in the early stages of development, ConnectWellSD will implement new technologies that will allow users to perform functions such as looking up a customer file, making and managing referrals, or sharing case notes.
Carrie Hoff, ConnectWellSD’s deputy director, says the impetus behind the web portal’s launching was the need to pull disparate data together to have a fuller view of how the individual is being serviced, in compliance with privacy and confidentiality. “Rounding up that picture sets ourselves up to collaborate across disciplines in a more streamlined way,” Hoff says.
Moving forward, with the ultimate goal of “whole-person centricity” in mind, San Diego health officials envision a future in which ConnectWellSD, along with San Diego Health Connect (SDHC)—the metro area’s regional health information exchange (HIE)—and the area’s “2-1-1 agency,” which houses San Diego’s local community information exchange (CIE), all work in cohesion to create a longitudinal record that promotes a proactive, holistic, person-centered system of care.
Yet as it stands today, “From a data ecosystem perspective, San Diego is still a work in progress,” Yphantides acknowledges. “But we’re looking to really be a data-driven, quantified, and outcome-based environment,” he says.
To this end, SDHC is an information-sharing network that’s widely considering one of the most advanced in the country. Once federally funded, SDHC is now sustained by its hospital and other patient care organization participants, and according to a recent newsletter, in total, the HIE has contracted with 19 hospitals, 17 FQHCs (federally qualified health centers), three health plans and two public health agencies.The regional HIE was shown to prove its value during last year’s tragic hepatitis A outbreak in San Diego County amongst the homeless population that resulted in 592 public health cases and 20 deaths spanning over a period of a little less than one year. In an interview with Healthcare Informatics Editor-in-Chief Mark Hagland late last year, Dan Chavez, executive director of SDHC, noted that the broad reach of his HIE turned out to be quite helpful during this public health crisis.
Drilling down, per Hagland’s report, “Chavez is able to boast that 99 percent of the patients living in San Diego and next-door Imperial Counties have their patient records entered into San Diego Health Connect’s core data repository, which is facilitating 20 million messages a month, encompassing everything from ADT alerts to full C-CDA (consolidated clinical documentation architecture) transfer.”
According to Chavez, “With regard to hep A, we’ve done a wonderful job with public health reporting. I venture to say that in every one of those cases, that information was passed back and forth through the HIE, all automated, with no human intervention. As soon as we had any information through a diagnosis, we registered the case with public health, with no human intervention whatsoever. And people have no idea how important the HIE is, in that. What would that outbreak be, without HIE?”
To this point, Yphantides adds that to him, the hepatitis A crisis was actually not as much about an infectious outbreak as much as it was “inadequate access, the hygienic environment, and not having a roof over your head.” Chavez would certainly agree with Yphantides, as he noted in Hagland’s 2017 article, “We’re going through a hepatitis A outbreak, and we’re coming together to solve that. We have the fourth-largest homeless population in the U.S.—about 10,000 people—and this [crisis] is largely a result of that. We’re working hard on homelessness, and this involves the entire community.”Indeed, while administering tens of thousands of hepatitis A vaccines—which are 90 percent effective at preventing infection—turned out to be a crucial factor in stopping the outbreak, there were plenty of other steps taken by public health officials related to the challenges described above. Per a February report in the San Diego Union-Tribune, some of these actions included “installing hand-washing stations and portable toilets in locations where the homeless congregate and regularly washing city sidewalks with a bleach solution to help make conditions more sanitary for those living on the streets.” What’s more, Family Health Centers of San Diego employees “often accompanied other workers out into the field and even used gift cards, at one point, to persuade people to get vaccinated,” according to the Union-Tribune report.
Yphantides notes that the crisis required coordinated efforts between the state, the city, and various other municipalities, crediting San Diego County for its innovative outreach efforts which he calls the “Uberization of public health,” where instead of expecting people to come to healthcare facilities, “we would come to them.” He adds that “hep A is so easily transmissible, and it would have been convenient to say that it’s a homeless issue, but based on how easily it is transmitted, it could have become a broader general population factor for us.”
Other Regional Considerations
Beyond the problem of homelessness in San Diego, which Jennifer Tuteur, M.D., the county’s deputy chief medical officer, medical care services division, attributes to an array of factors, some unique to the region, and others not: from the warm year-round weather; to the many different people who live in vastly different areas, ranging from tents to canyons to beaches and elsewhere; and to the urbanization of downtown and the building of new stadiums; there are plenty of other market challenges that healthcare leaders must find innovative solutions to.
For instance, says Yphantides, relative to some parts of the U.S., although California has made great strides in expanding insurance coverage, due to the Affordable Care Act—which lowered the state’s uninsured rate to between 5 and 7 percent—there are still core challenges in regard to access. “We’re still dealing with a fragmented system; like many parts of the U.S, we are siloed and not an optimally coordinated system, especially when it comes to ongoing challenges related to behavioral health,” he says, specifically noting issues around data sharing, the disparity of platforms, a lack of clarity from a policy perspective, and guidance on patient consent.
To this end, San Diego County leaders are looking to bridge the gap between those siloes while also looking to bridge the gap between the healthcare delivery system, having realized how important the broader ecosystem is, Yphantides adds. “But what does that look like in terms of integrating the social determinants of health? Who will be financing it, and who will be responsible for it? You have a tremendous number of payers who all have a slice of the pie,” he says.
Speaking more to the behavioral health challenges in the region, Yphantides says there are “real issues related to both psychiatric and substance abuse.” And perhaps somewhat unique to California, due to the cost of living, “we have tremendous challenges in relation to the workforce. So being able to find adequate behavioral health specialists at all levels—not just psychiatrists—is a big issue.”
What’s more, while Yphantides acknowledges that every state probably has a similar gripe, when looking at state reimbursement rates for MediCal, the state’s Medicaid program, California ranks somewhere between 48th and 50th in terms of compensation for Medicaid care. Put all together, given the challenges related to Medicaid compensation, policy, data sharing, workforce and cost of living issues, “it all adds up with access challenges that are less than ideal,” he attests.
In the end, those interviewed for this story all attest that one of the unique regional characteristics that separates San Diego from many other regions is the constant desire to collaborate, both at an individual level and an inter-organization level. Tuteur offers that San Diego residents will often change jobs or positions, but are not very likely to leave the city outright. “That means that a lot of us have worked together, and as new people come in, that’s another thing that builds our collaboration. I may have worn [a few different] hats, but that commitment to serving the community no matter what hat we wear couldn’t be stated enough in San Diego.”
And that level of collaboration extends to the patient care organization level as well, with initiatives such as Accountable Communities for Health and Be There San Diego serving as examples of how providers on the ground—despite sometimes being in fierce competition with one another—are working to better the health of their community. “Coopetition—a hybrid being cooperation and competition—describes our environment eloquently,” says Yphantides.
Learn more about San Diego healthcare at the Southern California Health IT Summit, presented by Healthcare Informatics, slated for April 23-24, 2019 at the InterContinental San Diego.