developing an innovative service integration model in los angeles

SPA 3 & 4 CASE STUDY

DEVELOPING AN INNOVATIVE SERVICE INTEGRATION MODEL IN LOS ANGELES

Los Angeles County Department of Health Services • Public Health

July 2005

SPA 3 & 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

San Gabriel Valley and Metropolitan Service Planning Area Health Office (SPA 3 & 4)

Developing an Innovative Service Integration Model in Los Angeles : SPA 3 & 4 Case Study July 2005

SAN GABRIEL VALLEY SERVICE PLANNING AREA (SPA 3)METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312Los Angeles, California 90012(213) 240-8049

The Best Practice Collection is a publication of the San Gabriel Valley (SPA 3) and Metropolitan Ser-vice Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 3 & 4 as the source.

Internet: http://www.lapublichealth.org/SPA 3Internet: http://www.lapublichealth.org/SPA 4

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District

Zev Yaroslavsky, Third District

Don Knabe, Fourth District Michael D. Antonovich, Fifth District

DEPARTMENT OF HEALTH SERVICES

Thomas L. Garthwaite, MD.Director and Chief Medical Officer, Department of Health Services

Jonathan E. Fielding, MD, MPH, MBA.Director of Public Health and County Health Officer

BEST PRACTICE COLLECTION TEAM

M. Ricardo Calderón, Series Editor Manuscript Author & SPA 3 & 4 Area Health Officer

Cristin Mondy, MSN, MPH, CNS. Manuscript Author & Area Nurse Manager, SPA 4

Sheree Poitier, MD. Manuscript Author & Area Medical Director, SPA 4

Carina Lopez, MPH. Project Manager, Information Dissemination Initiative

Photo: Courtesty of SPA 3 & 4 Area Health Office

At a GlanceThe SPA 3 & 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 3 & 4 Infor-mation Dissemination Initiative created with the following goals in mind:

To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs

To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy mak-ers and funding agencies regarding health promotion and disease prevention and control

To share information and lessons learned in SPA 3 & 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states

To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations

The SPA 3 & 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collec-tion concept. Topics will normally include the following:

1. SPA 3 & 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and pro-poses options and solutions.

2. SPA 3 & 4 Profile: A technical overview of a topic that provides infor-mation and data needed by public, private and personal health care providers for program development, implementation and evaluation.

3. SPA 3 & 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well be-ing of populations.

4. SPA 3 & 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and know-how on a topic or an example of a best practice.

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Improving DHS Performance: SPA 4 ViewPoint Developing an Innovative Service Integration Model In Los Angeles : SPA 3 & 4 Case Study July 2005

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DEVELOPING AN INNOVATIVE SERVICE INTEGRATION MODEL IN LOS ANGELES

Table of Contentsi. EXECUTIVE SUMMARY 4

I. PROJECT BACKGROUND: THE OVERVIEW 5

II. PROBLEM STATEMENT: THE CHALLENGE 6

III. PROJECT APPROACH: THE INNOVATIVE SOLUTION 6

IV. PROJECT METHODOLOGY: THE PROCESS 7

V. PROJECT ACCOMPLISHMENTS: THE OUTCOMES 8

VI. PROJECT SUMMARY: THE BENEFITS 9

VII. APPENDIX A: SERVICE INTEGRATION PROJECT AWARDS 11

1. Board of Supervisors Scroll

2. Board of Supervisors Certificate of Recognition

3. National Association of Counties Achievement Award

VIII. APPENDIX B: INTEGRATION PLANNING GUIDELINES (UNEDITED) 14

Developing an Innovative Service Integration Model In Los Angeles County : SPA 3 & 4 Case Study July 2005

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EXECUTIVE SUMMARY

i. EXECUTIVE SUMMARY

Integration efforts of the health system in Los Angeles have rarely worked and even failed due to differ-ing definitions of integration and “co-location, expansion and take-over” initiatives resulting in health care organizations and providers working independently and/or duplicating efforts. Over the past few decades, counties, health experts and health care providers have used the word “integration” with a variety of mean-ings and in different situations. To some, integration may mean a new organizational structure merging various disease control programs or services. For others, integration means regular coordination through information dissemination and exchange among decision mak-ers and program managers. Others view integration as the sharing of resources such as transportation among different providers, expand-ing services or co-locating different institutions in the same building, or adding tasks to already overbur-dened staff. However, integration is not just service provider networking, community development, facility co-location, expansion or take-over, direct service gap filling, increasing access to services, pleasant part-nerships, or a great vision and few concrete activities. All of these views fail to appreciate that the aim of integrating services is to enable the overall health system to provide the right care in the right place to more people in terms of both quantity and quality.

Therefore, the Metropolitan Service Planning Area Health Office (SPA 4) transformed a “Co-Location Project” between the Los Angeles County Department of Health Services (DHS)

and The Los Angeles Free Clinic (LAFC) into a Service Integration Project (SIP). This was accomplished at the Hollywood/Wilshire Health Center (HWHC) by promoting a shared-vision and four Fundamental Integration Principles (Sharing of Responsibilities, Enhanced Coverage and Quality, Customer Focused Ser-vice, Optimization of Resources), and organizing and deploying 5 Integra-tion Planning Teams (Clinical Services, Business Office and Facility Manage-ment, Human Resources, Information Technology, Marketing and Develop-ment). This enabled DHS to provide appropriate services to more people, closer to where they live and work, at an earlier stage of disease develop-ment, and as part of a continuum of care process. As a result: (1) HWHC has seen a 70% increase in patient load, (2) patients have increased access to primary health care and public health services, (3) a Model Center of Community Health and Social Services is being created, and (4) status quo is being replaced by value added public health initiatives that are moving public health into the 21st Century.

The First Anniversary Celebration of the HWHC Service Integration Project was held on April 4, 2003. The event was placed into the larger context of what was achieved by the SPA 4 Area Health Office by commemorat-ing more than just, and beyond what was, a successful partnership be-tween the DHS and LAFC. The event celebrated the restructuring of the way business was traditionally done, the strengthening and promotion of excellence in service delivery, and the delivery of enhanced services to the community.

Phase I of the Service Integration Project included the integration of Primary Care and Public Health Services. Phase II of the project was implemented three years later by adding select Specialty Care and Social Services in 2005. The safety net to Hollywood’s underserved populations was expanded through DHS focus on the Service Integration Model developed by the SPA 4 Area Health Office. In April 2003, the Los Angeles County Board of Supervisors awarded a Scroll for the Revitalization of the Hollywood/Wilshire Health Center with the renovation of the facility and restoration of primary care medical services through and integrated service model. In Octo-ber 2003, The Board of Supervisors awarded Certificate of Recognition to the Service Integration Project for “Enriching Lives, Quality and Pro-ductivity” and Los Angeles County received the 2004 Achievement Award of the National Association of Counties in recognition for an innova-tive program which contributes to and enhances county government in the United States (Appendix A).

INTEGRATION PRINCIPLES

1. Shared Responsibilities

2. Enhanced Coverage and Quality

3. Customer-Centered Services

4. Optimization of Resources


PROJECT BACKGROUND

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I. PROJECT BACKGROUND: THE OVERVIEW In 1997, following unprecedented service cuts in the county system that left tens of thousands of people without access to primary care, the Los Angeles County Department of Health Services sought to partner with community clinics in an effort to continue services for its patients. Years of shrinking public dollars and an ongoing State and County budget crisis over the previous decade changed the way all agencies delivered health care in Los Angeles. In order to bridge the gap, continue to serve county residents and, more importantly, develop an integrated health services system, strategic alliances and partnerships were created with non-profit community clinics. During this time, there was much discontentment and frustra-tion from DHS patients, customers and the community due to a frag-mented patchwork of health and human services. It was very difficult for the people to navigate through the health care system and obtain the health care services that they needed.DHS attempt to develop an inte-grated health services system with the private sector was based on three fundamental strategies:

(1) “Co-Location Projects” where a public and a private health provider utilized the same facility to service clients retaining each ownership of clients and autonomy of operations,

(2) “Expansion Projects” that increased the size, volume, quantity or scope of services provided by an existing DHS health center, and

(3) “Take-Over Projects” where private providers assumed total control, management and/or responsibility of DHS facilities.

The Los Angeles Free Clinic was one of the clinics selected to enter into the Public/Private Partnership Pro-gram by the Third District of the Los Angeles County Board of Supervisors (BOS). A co-location project between LAFC and the Hollywood/Wilshire Health Center was envisioned and multiple site visits were made by LAFC, BOS and DHS staff to plan for the project and discuss the most appropriate areas to co-locate LAFC services. In August 1999, the newly appointed Area Health Officer for the Metropolitan Service Planning Area (SPA 4) was charged with the respon-sibility to bring this project to fruition.

DEFINING THE PROBLEM: MACRO LEVEL

•Government has a duty to assure the public’s health

•Government cannot do it alone, other sectors have a role to play

• Need for inter-sectoral engagement

DEFINING THE PROBLEM: MICRO LEVEL

10 million people

236,000 homeless

53% low literacy rate

31% no medical insurance

35% no dental insurance

DHS budget constraints: Reduction in force and closure of clinics, emergency departments, hospital services and trauma centers

Figure 1. Assuring the population’s health


PROBLEM STATEMENT & PROJECT APPROACH

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II. PROBLEM STATEMENT: THE CHALLENGE

The effects of barriers to health care access were felt in the late 1990’s and early 2000’s throughout Los Angeles County (LAC), but nowhere were they more noticeable than in SPA 4. Resi-dents of Metropolitan Los Angeles represented 24.75% of all cases of advanced HIV/AIDS in the county, 10.7% of cases of Hepatitis C, 24.3% of cases of Tuberculosis, and 13.6% of cases diagnosed with a Sexually Transmitted Disease (STD). As the unemployment rate grew the rate of homelessness and under/uninsured people grew also. Approximately 48% of SPA 4 residents had no health insurance and over 8% reported be-ing homeless at least once within the last 5 years. Additionally, an estimated 44% of the population of SPA 4 lived at the 200% Federal Poverty Level ($36,800 per year for a family of four). For most families, it was difficult to access health care because services were scattered throughout a large area, scheduling of appointments was difficult, and there was limited quality, culturally sensitive health care. Clo-sures of health centers and services and a DHS budget shortfall close to one billion dollars aggravated this situation. Consequently, one of the DHS strategies to improve the per-formance of the health system and fill the gaps in services in SPA 4 was the implementation of a Co-Location Project between LAFC and HWHC.

The above described situation was further compounded by the fact that HWHC staff had not been officially briefed, consulted or informed about the co-location project with LAFC. This resulted in mixed feelings among staff ranging from fear of job loss, displacement, uncertainty, confu-

sion, frustration, disappointment, lack of appreciation for their work and contributions, and lack of value for public health services, to reluctance and rejection to partner with LAFC. Unfortately, this was indirectly and involuntarily created by two years of site visits that left messages regarding what LAFC “wanted and was going to be granted” rather than what LAFC was contributing to or bringing to HWHC and the health district.

III. PROJECT APPROACH: THE INNOVATIVE SOLUTION

The SPA 4 Area Health Office was assigned the responsibility to support the DHS co-location of LAFC at the Hollywood-Wilshire Health Center, including support to the renovation of the facility. In light of low morale is-sues already described, in addition to

noticeable integration gaps between DHS Personal and Public Health Services as well as between DHS and private providers, SPA 4 conceptual-ized a Service Integration Project to:(1) bring LAFC and HWHC staff together on a common vision and mission, (2) advocate for “integration” instead of “co-location”, (3) develop project ownership among LAFC and HWHC staff, (4) motivate and boost the morale of public health staff, (5) educate about and raise the importance of the core functions of public health,(6) better serve community residents and patients, and (7) challenge LAFC/HWHC staff to develop a unique integration model worthy of replication in other local, state and national settings. Service Integration Planning Guidelines (Ap-pendix 2) were developed in January 2000 and presented to two subse-quent LAFC Chief Executive Officers and their Management Teams who bought into the vision and con-tributed thereafter to promote the integrated health services approach. In turn, SPA 4 transformed the DHS co-location strategy into a feasible Service Integration Model by devel-oping and promoting the following integration rationale:

• PROJECT PURPOSE: Create a Model Center of Community Health and Social Services which will be key to promoting and building stronger and healthier families and communi-ties.

• PROJECT GOAL: Integrate four project components –primary care, specialty care, public health programs and services, and social and commu-nity services—through the collab-orative efforts and complementary capabilities and resources of the two partnering institutions.

Integration is not...

• Service provider networking• Community development• Direct service gap filling• Increasing health care access• Pleasant partnerships• A great vision with few concrete activities• New organizational structure• Regular coordination through information sharing • Sharing resources• Co-location of different institutions within the same building


PROJECT METHODOLGY

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FUNDAMENTAL INTEGRATION PRINCIPLES:

o Sharing of Responsibilities, in-cluding vision, governance, physical infrastructure, and complementary services for client, program and com-munity betterment outcomes.

o Enhanced Coverage and Quality, meaning better services at the point of first encounter, closer to those in need and where people live and work, provided by a combination of providers, and constituting the first element of a continuing health care process.

o Customer Centered Services, that is, language and culturally sensitive services for individuals, families and the community with a common in-take/reception and seamless service delivery.

o Optimization of Resources, in other words, to capitalize on and maximize the use of LAFC and DHS capabilities in a complementary fash-ion avoiding duplication of efforts and services.

IV. PROJECT METHODOLOGY: THE PROCESS

The renovation of HWHC to accom-modate LAFC and reorganize public health services was completed in March 2002. The Service Integration Project was seriously challenged by multiple renovation and staff issues connected to cumbersome contract-ing, monitoring and oversight issues expected in a bureacratic setting lacking renovation performance ac-countability and sanctioning. Never-theless, the vision and determination of the LAFC/HWHC Leadership Team

maintained the project on course by addressing emergent construc-tion and personnel issues and, most importantly, encouraging and ral-lying staff consistently towards the creation of a Model Center of Com-munity Health and Social Services. While both partners shared similar values and ideals, a long list of chal-lenges to integrated health services emerged. The crucial question was “how would it be possible to inte-grate two different businesses with different policies, procedures and practices and yet provide seamless, comprehensive services for patients”? As with any integration project, there are possible risks including a shared liability, conflict in management styles, resentment, and funding dis-parities for the institutions. In order to address these and other issues, five Service Integration Planning Teams were created. Each team consisted of experts in particular subject areas that reported regularly to the SIP Integration Leadership Team that monitored process ensuring account-ability as follows:

1. Clinical Services Integration Plan-ning Team: This team addressed the issues related to the type of services that would be provided by each partner keeping in mind the goal of providing seamless, comprehensive care to patients without duplication of efforts. Other issues tackled by this team included how to deal with walk-in patients as well as the patient referral process within the center.

2. Business Office and Facility Management Integration Planning Team: This team addressed building concerns such as janitorial and secu-rity services and designed the shared registration area to present a seam-less appearance to patients. Although

an integrated medical record was the ideal, existing HIPAA (Health Insur-ance Portability and Accountability Act), County and State regulations prohibited it. This team explored al-ternative options on how the medical records systems should be handled. Other issues addressed by the team included assignment of work spaces and parking spaces.

3. Human Resources Integration Planning Team: Issues discussed by this team included opportuni-ties to share employee training and incorporating volunteers into service provision. This team was also tasked with developing recommendations on how to respond to employees’ reactions, how to inform them of the process, how to anticipate and deal with Union issues, and how to keep the workforce motivated.

PURPOSE OF INTEGRATION

To enable the overall health system:• to provide appropriate services to more people• closer to where they live and work• at an earlier stage of disease development,• at the point of first encounter• by a combination of providers• constituting the first element of a continuing health care process.

SPA 3 & 4 Area Health Office


4. Information Technology Inte-gration Planning Team: This team addressed issues related to integrat-ing two separate information systems including the selection of the most appropriate telephone system for the center.

5. Marketing and Development Integration Planning Team: Issues addressed by this team included advertising and marketing strategies, particularly how to introduce the new center to the community. Coordina-tion of health information, educa-tion, communication and outreach services were also discussed by this team.

The five Integration Planning Teams were organized and deployed in No-vember 2001 to review and implement integration guidelines in their respec-tive areas. Teams met extensively during a 3-month period (January – March 2002) and reported monthly to the SIP Integration Leadership Team consisting of LAFC and SPA 4 Senior Leaders. The official start date of the Service Integration Project was April 1, 2002. Since then, monthly meetings continue to assess progress to date, further define the meaning and extent of integration, and make changes and adjustments as needed.

V. PROJECT ACCOMPLISH-MENTS: THE OUTCOMES AND LESSONS LEARNED

The LAFC and SPA 4 Area Health Office shared the values of providing high quality, non-judgmental, patient–cen-tered care. Together through this part-nership, the delivery of broader, more comprehensive services at an earlier stage of disease development, to more people and closer to those in need by the combination of two providers was possible constituting the first element of a continuum of health process. Con-sequently, the SIP goal to better serve patients and customer at their point of first encounter was fulfilled.

Figure 2. Integration Teams

PROJECT ACCOMPLISHMENTS

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PROJECT ACCOMPLISHMENTS & PROJECT SUMMARY

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Implicit in the idea of integration was the customer-focused care principle. Integration of programs and services was viewed from and based upon the patient’s perspective, i.e. an individual seeks help and health care services at HWHC where comprehensive –prima-ry and specialty care combined with public health and social services-- are delivered independently of who [which partner] provides the service. From the patient’s perspective, he/she can resolve his/her medical, public health and/or social need at HWHC, not at the Los Angeles Free Clinic housed in the facility or at the DHS clinics located in the health cen-ter. Hence, HWHC is not a “co-location of independent entities” but rather an “integrated center of programs and services” for individuals, families and the community based on a true, col-laborative partnership. The vision of the center to provide patients a place that could meet most of their health and social needs was also fulfilled. Also, this was strongly supported by language and culturally sensitive services, a common intake reception area, and seamless service delivery.

Integration of programs and services was also viewed from an optimiza-tion perspective; that is, aiming to develop a partnership to the utmost extent in order to obtain the most ef-ficient use of DHS and LAFC capabili-ties. Avoiding duplication of services and eliminating wasteful spending was essential. For example, instead of having two STD and TB Clinics at HWHC, what was working well was kept in place and new services were added to satisfy unmet needs and fill the gaps in other services or special-ties, i.e. primary care and selective specialty care. This allowed both partners to contribute to each other with their particular strengths and expertise.

What occurred between DHS and LAFC is more than just, and beyond what is, a successful partnership. It is indeed a model Service Integration Project that: (1) restructured the way business was done in Los Angeles, (2) strengthened and promoted excellence in service delivery, and (3) provided better services to commu-nity residents.

The “revitalized” Hollywood-Wilshire Health Center began to operate in April 2002 as a Service Integration Project, a joint venture between DHS and LAFC. Initially, primary care was integrated with public health servic-es. Three years later, select specialty care and social services were added. By late summer of 2005, the ser-vices that were offered at the center included primary and specialty care; treatment of STD and TB; immuniza-tion services; refugee health services; dental services; vision screening; transportation; health promotion/risk reduction prevention programs; basic laboratory support; mental health and case management; and public health nursing services. In addition, there was a dispensing pharmacy on site and HWHC offered services to infants, children, adolescents, adults and the elderly.

This collaborative venture provided stability, expanded access to health-care, diversified services, delivered high quality care and “one stop shop-ping” for patients, and allowed better utilization of resources. The HWHC SIP inaugurated a bold experiment that became a model of healthcare delivery, cementing the relationship between DHS and LAFC through a mutually beneficial and cost-effec-tive approach. Most importantly, it marked a huge boost in service for patients who are now able to

visit a single location to be seen by a primary care physician and receive public health services free of cost.

As a result of this Service Integra-tion Project, HWHC has seen a 70% increase in the patient load. Commu-nity residents have increased access to primary health, public health, specialty care and social services. SIP has made it easier for patients to ac-cess services by providing them with a single point of entry and allowing them to receive in one facility a broad range of assistance normally provid-ed in different locations. In addition, a Model Center of Community Health and Social Services was created and, more importantly, status quo was re-placed by value-added public health initiatives that are moving healthcare into the 21st Century.

VI. PROJECT SUMMARY: THE BENEFITS

The purpose of this publication was to showcase the development and implementation of an integrated health services initiative as a concep-tual model and framework for “trou-ble-shooting and problem-solving” of health issues, increasing access to health care services, developing leadership teams and workforces, and enhancing the performance of the Los Angeles County health system as a whole. As such, there is no discussion about budget implica-tions, expenditures to renovate the Hollywood/Wilshire Health Center or funding given to LAFC under the Public/Private Partnership Program. At the time of this project, the total DHS funding for this program is more than $40,000.00 for over 30 commu-nity clinics and a cost-effectiveness, cost-utility or cost-benefit analysis is beyond the scope of this publication.


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The Service Integration Project pro-vides services to community residents in an atmosphere of cooperation, qual-ity and accountability. The project al-lowed residents to access high quality essential primary care, specialty care and public health and social services in a single location without having to drive across town. LAFC and SPA 4 patient loads increased by 70% in 2002 (from 36,000 to 62,000 clinic visits per year). Additionally, public health patients gained a “medical home” and access to primary and specialty care providers that were not easily avail-able prior to the integration. Similarly, primary care patients are able now to access public health services without having to leave the building.

PROJECT SUMMARY

Finally, we trust that this integration approach will be useful to public, private and non-profit medical and public health departments, organiza-tions, programs and providers as they continue to improve the quality of services, enhance the performance of their systems and developed integrat-ed health services models. The lessons learned from this project have been instrumental in the SPA 4 Area Health Office for capacity building and leader-ship development purposes, as well as a motivation to develop an approach to better integrate the DHS personal and public health functions.

Figure 3. Service Integration Project Model


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APPENDIX A: Board of Supervisors Scroll

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APPENDIX A: Board of Supervisors Certificate of Recognition


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APPENDIX A: National Association of Counties Achievement Award


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APPENDIX BINTEGRATION PLANNING GUIDELINES (UNEDITED)

Metropolitan Service Planning Area Health Office, DHS/PHP&SJanuary 28, 2000

This concept paper reflects the Metro SPA Area Health Office general thinking to date to operationalize service integration at the Holly-wood/Wilshire Health Center. It is not meant to be comprehensive at this time, but rather a starting point for discussion across organizational lines. It will be subject to modifica-tion and refinement as we continue to learn how to integrate public health, personal and private partner health services. We hope this docu-ment will be useful for developing a Memorandum of Understanding and/or Contract between the DHS and the Los Angeles Free Clinic.

1. Project

Hollywood/Wilshire Health Center’s Integration Project

2. Principal Partner InstitutionsLos Angeles Free Clinic [LAFC]Metropolitan Service Planning Area Health Office, DHS/PHP&S

3. Project Managers

Mary L. Rainwater, LCSW, Executive Director, LAFC M. Ricardo Calderón, MD, MPH, Area Health Officer – Metro SPA 4. Strategic Intent

Shared [1] Vision [2] Governance [3] Physical Infrastructure [4] Complementary Programs and Services

5. Integration Rationale

5.1. Purpose

The purpose of the project is to cre-ate/develop a model center of com-munity health and social services, which will be key to promoting and building stronger and healthier fami-lies and communities.

5.2. Goal

The project aims to integrate four program components --primary care, specialty care, public health pro-grams and services, and community services, through the collaborative efforts and complementary capabili-ties and resources of two partnering institutions, the Los Angeles Free Clinic and the Metropolitan Service Planning Area Health Office of the Department of Health Services.

5.3. Fundamental Principles

5.3.1.Customer focused/centered services

Integration of programs and services is viewed from and based upon the client’s or patient’s perspective, i.e., an individual seeks help and health care services at the Hollywood/Wilshire Health Center [HWHC] where comprehensive – primary and specialty care combined with public health and community services - are delivered independent-ly of who [which partner] provides the service. From the patient’s per-spective, he/she can resolve his/her medical, public health and/or social needs at HWHC, not at the LAFC ser-vices housed in this center nor at the DHS services located in it. Therefore, the HWHC is not a “co-location of independent entities” but rather an “integrated center of programs and services” for individuals, families and the community based on a true, col-laborative partnership.

5.3.2. Optimization of Resources

Integration of programs and services is also viewed from an optimiza-tion perspective; that is, aiming to develop a partnership to the utmost extent in order to obtain the most efficient use of DHS and LAFC capa-bilities. Hence, a second integration principle is to capitalize on and maxi-mize the use of current HWHC and LAFC resources in a complementary fashion avoiding duplication of time and efforts and wasting of resources. For example, instead of having two STD and TB Clinics at HWHC, what is working well is kept in place and new services are added to satisfy unmeet needs and fill the gaps in other ser-vices or specialties, i.e., primary care and selective specialty care.

5.4. Scope of Work

HWHC’s “community health services” is essential medical and public health care based on practical, scientific and socially acceptable methods and technology. It will be made univer-sally accessible to individuals and families in the community through their full participation at an afford-able cost. HWCH’s integrated services will be one of the central functions and the main focus of the Hollywood/Wilshire District Health System and of the social and economic develop-ment of the community. It will be a first contact point for the individual, the family and the community with the Public/Private Partnership Health System, bring-ing health care as close as possible to where people live and work, and constituting the first element of a continuing health care process. The comprehensive community health services will rest on the following elements:• Primary medical care for children and adults, including reproductive health services.

APPENDIX B: Integration Planning Guidelines (UNEDITED)


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• Immunizations against the major infectious diseases• Appropriate treatment of common diseases and injuries• Categorical clinics for specialty care needed by the commu nity including referral services and agreements with other health care providers• Health promotion, risk reduction and disease prevention programs including promotion of proper nutrition and education on prevail- ing health problems and methods of prevention and control• Provision of essential drugs and/or prescriptions • Public health investigations • Basic laboratory support and referral services and agreements• Community meeting and information services including center- based and outreach programs, i.e., social, educational and legal assistance and prevention and response programs for domestic violence, child abuse, elder abuse and sexual assault. • Case Management referrals and information.• Flexibility to adapt programs and services to meet changes in community needs and priorities

6. Description of Key Project Compo-nents

6.1. Triage Services Currently DHS/HW provides Com-municable Disease Triage services through Registered Nurses, 98% tuberculosis screening and 2% communicable disease treatment respectively. The LAFC provides tri-age and referral services to determine same day walk in appointments, and information regarding accessing LAFC appointments by phone, as well as community referrals.

With the integration of DHS and LAFC services at HWHC, Triage Services must be enhanced to provide internal and external referrals that meet the specific needs of those requesting medical service consultation and intervention. Historically, all services offered in County Public Health Cen-ters begin with the Registration Win-dow as the entrant’s first “stop”. After the person is financially screened, she/he is then referred to a specific categorical clinic or to Triage.

We propose a new system, not unlike that used in Emergency and Urgent Care Centers, where the entrant, unless pre-appointed to a clinic, is directed to a triage office, seen by a staff (DHS/LAFC staff composition to be determined), and screened for the type of problem. From the triage area, the staff will determine what type of initial evaluation, clinical or social service is needed for the client –immunizations, tuberculosis, STDs, refugee’s health services, primary and specialty services, financial screening for insurance and financial assistance, dental, vision, nutrition, smoking cessation, transportation, language, child care, etc.-- and, when on-site service is indicated, direct the client appropriately. Triage Services would facilitate access to services directly through interacting with the appro-priate staff and making the patient’s various stops through the system as simple and seamless as possible, in-cluding referring and/or assisting the client in attaining service off-site.

6.2. Management of Tuberculosis

Trained and certified physicians staff the TB Clinic at HWHC. This clinic also has associated infrastructure to provide the patient an array of services to facilitate adherence with prescribed medication. These ser-

vices include culturally and linguisti-cally compatible outreach and clinic personnel to provide transportation, directly observed therapy and inter-pretation. In addition, incentives are often provided to raise the priority of appropriate care for their disease. Housing is provided for the homeless and food for the hungry, as well as clothing and other essential needs in exchange for adherence to treatment regimens. Bus passes and tokens are also utilized to overcome transpor-tation barriers when necessary or effective. These services are accessed through the current HWHC’s TB clinic and its methodology has been effective in the identification and resolution of barriers to completion of therapy for TB disease.

In Los Angeles County, directly observed therapy is the “standard of care” for all TB cases and suspects. Few, if any, private providers or community-based primary care clin-ics have the infrastructure to support these extensive outreach efforts. The DHS public health clinics also have Public Health Investigators whose role it is to follow-up on recalcitrant and non-adherent patients to return them to treatment. If all else fails, DHS has the authority to legally detain patients that, despite our best efforts, continue to place the public at risk for transmission. Public Health Nursing is involved with the family and other close contacts to these patients to provide screening, evalua-tion and education. The entire range of services is available to the patient population under the umbrella of the DHS TB clinic. There are no efficien-cies to be realized by fragmenting these services. Having patients clini-cally managed by LAFC and provided support (case management) services by public health is unnecessarily complicated with no advantages to the patient population.



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The integration of a TB public health clinic and a private non-profit pri-mary care clinic can provide benefits to patients that neither entity can provide alone. TB patients often suffer from other conditions and the ability to refer a TB patient for care of these conditions to a co-located pri-mary care clinic would be a substan-tial improvement over referral to a County hospital. Likewise, the ability of a primary care clinic to refer a patient with TB-like symptoms identi-fied through screening to an on-site public health clinic specializing in TB management would be an improve-ment over an off-site referral.

Therefore, the public health TB clinic will:

• remain responsible for patient medical and case management [clinical services for the screen-ing, diagnosis and treatment of tuberculosis including prophylaxis/preventive therapy and field services of observed medication therapy, monitoring of treatment compliance and contact tracing],• serve as a referral source for all tu-berculin skin test reactors for whom active disease needs to be ruled out, • assist and consult with the LAFC staff as requested, along with as-sistance from the DHS TB Control Program when medically indicated for the evaluation of tuberculosis, and• monitor the treatment of tuber-culosis in patients with concomitant illnesses managed by LAFC.

The LA Free Clinic will:

• refer TB patients and/or manage them in conjunction with the HWHC TB clinic,• serve as a referral source for patients with other acute or chronic conditions,

• provide primary care for tuberculo-sis patients as indicated and avail-able and care for diabetes and other chronic conditions, as appropriate.

The DHS and LAFC staff will work jointly to coordinate care for the patient through both informal con-sultations and potentially, formal case conferences, and both entities will continue to follow mandated report-ing requirements. However, when a high risk situation arises or is made apparent, LAFC and DHS will refer to each other for immediate interven-tion, i.e., LAFC evaluates someone who they suspect has active TB or DHS sees someone with grossly elevated blood glucose.

6.3. Management of Refugee’s Health (Note: this whole area needs addi-tional collaboration)

The Refugee Health Clinic may provide the best opportunity for not only cooperative co-location, but also true collaboration and integration be-tween DHS and LAFC. While screen-ing services have been provided to the refugee population by culturally sensitive and linguistically competent teams at both Hollywood and Central Health Centers, the DHS current level of staffing cannot accomplish the new requirement for a complete history and physical. In order to ac-complish what is now required, the TB Control Program contracts with H. Claude Hudson Comprehensive Health Center and the Los Ange-les County-University of Southern California Medical Center to utilize a Nurse Practitioner currently providing primary care services at HWHC. It is not anticipated that this arrangement will be practical in the future as LAFC will replace the services currently provided by Hudson.

The TB Control Program has a Nurse Practitioner position funded by the State to provide expanded screening services to the refugee population. DHS physicians are very specialized and aren’t comfortable acting as preceptor for the Nurse Practitioner. LAFC physicians practice general medicine and could provide the oversight needed to accomplish the expanded screening utilizing a Nurse Practitioner. The compensation for preceptor services could be negoti-ated at a later date. It would also be possible to fund a Nurse Practitioner position for LAFC, if such an arrange-ment offers advantages to LAFC. Any time not utilized in the evaluation of refugees would be available to serve in LAFC clinics. There may be other variations that could be even more advantageous and the TB Control Program is open to further discus-sions in this matter.

The Refugee Clinic at HWHC evalu-ates approximately 100 refugees per month, while the clinic at the Central Health Center sees 125. Many health problems, minor and severe, requir-ing various levels of referral and medical management appear in this population. Referrals are currently made to hospital-based clinics for fol-low-up, as no comprehensive primary care services are available in either of these two public health centers. Referrals could be made just as easily to the LAFC with refugee health team members providing the necessary interpretive and support services. This may be more convenient for the patient population and would at the very least provide a referral option for these patients. Refugees are eligible for Medi-Cal thirty days after their arrival. This could provide a rev-enue stream for LAFC with minimal investment in eligibility screening as sponsors have often cleared this



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hurdle prior to medical evaluation in the refugee clinic.

6.4. Management of Sexually Transmit-ted Diseases [STDs]

The Hollywood/Wilshire District is a unique area since it has a considerable number of street youth; it is a portal of entry for immigrants primarily from the former Soviet Union where both TB and Syphilis incidence is high and it has STD rates near those of LA County “core districts," i.e., highest number of reported congenital syphilis among LA County’s 23 Health Districts, and top rank in reported chlamydia and gonor-rhea cases.

The collaborative partnership between DHS and LAFC can strengthen and expand STD/HIV prevention services, maintain and expand partner services, maintain the DHS categorical STD clinic as a center of excellence, and create collaborative opportunities to develop top-quality services such as potential joint case conferences, STD program-credentialed clinical staff, participation in STD Control Program in-service education programs [3rd Friday of each month] and joint quality assurance activities.

Therefore, the proposed operation and management of STDs at HWCH will comprise the following:

• Offer choices to clients/patients to the maximum extent possible• Direct callers or walk-ins primarily to the DHS STD clinic • Use compatible intake, interview and exam processes, as possible• Use non-intrusive testing [first- voided urine, oral mucosal transu date, etc.]• Provide joint access to on-site facil-

ity laboratory services, as possible• Initiate partner services at initial visit• Offer HIV counseling and testing • Provide CDC-recommended single- dose oral treatments• Comply fully with Confidential Morbidity Reporting• Encourage enrollment in LAFC as a “medical home”• Offer immunizations, information and/or referrals, i.e., Hepatitis A & B• Provide referrals to alcohol/drug treatment and mental health services• Provide transportation assistance if necessary, i.e., bus tokens• Share written resources, i.e., treatment guidelines, case definitions, manuals, Public Health Newsletter, STD Examiner, etc.

Both DHS and LAFC will continue to di-agnose and treat sexually transmitted diseases as they currently are including mandated reporting requirements. The difference is that public health will do immediate contact interviewing and has the capacity for rapid HIV test-ing. On triaging, DHS will be the pri-mary referral for a single STD episode. Patients will access care through LAFC if other problems exist or they are ex-isting LAFC patients. When a high-risk situation exists or is made apparent, DHS and LAFC will refer to and consult with each other for immediate inter-vention, i.e., when immediate contact interviewing is important, LAFC has a client with +STD, possible incidents of child abuse, etc.

6.5. Management of Immunization Ser-vices (Note: this whole area needs to be revisited given the funding planned for the site/visits)

Currently both DHS/HWHC and LAFC

provide immunization services. Both are non-profit providers receiving their vaccine from the DHS Immunization Program. Both adhere to the Immuni-zation Program guidelines for age of administration, reporting procedures and annual audits. The difference is that LAFC also provides adult immu-nizations by purchasing vaccine. To consolidate services and simplify ac-cess for patients, we propose that LAFC provide all immunization services in the Hollywood/Wilshire Health Center. The exception will be the DHS annual Flu Program and periodic outreach clinics.

6.6. Laboratory Services

Currently, the HWHC does not have a laboratory onsite. Testing to rule out communicable diseases is sent to the DHS Central Laboratory and any other tests, such as complete blood counts, blood glucose and chemistries are done at the LAC+USC Medical Center Laboratory. The DHS Public Health and the Personal Health clinics utilize both laboratories.

Per physician orders, nursing is responsible for the collection of all lab specimens. Specimen collection includes blood, urine and sputum, as well as throat, lesion and rectal swabs. On occasion, specimens from animals suspect in communicable disease investigation are also collected. After collection, specimens are labeled and packaged for safe transport, and placed in the HWHC Business Office for pickup by couriers from each lab site. Couriers pick up tests daily. The processing time for both laboratories is between three to seven days including a procedure for “critical value” result notification by both labs. Critical value



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notification for LAC+USC Laboratory is conducted by the LAC+USC Customer Care Center for both Personal and Public Health clinics. Public Health con-ducts its own notification for critical values.

A small on-site laboratory capability is proposed by LAFC as follows for rapid turnaround of simple diagnostic tests for common ambulatory medical conditions, thus minimizing referrals to an outside laboratory:

• pregnancy tests• urine dip and microscopic• finger stick glucose and hemoglo- bin• rapid strep • wet mounts/KOH preps• cholesterol/cbc/simple blood chemistry• phlebotomy to send out blood specimens• preparation of samples to send out for microbiological exami- nation, pathology, (i.e., paps, stool culture), etc.• Injection and TB testing would be conducted by either nursing or laboratory personnel

The LAFC would be responsible for the above laboratory services at the HWHC and provide lab technician coverage for any clinic session.

6.7. Dispensary/Pharmacy Services

There are no on-site pharmacies in any Public Health facilities and, therefore, pharmacy services are primarily con-ducted by health center nursing staff. The Community Health Services [CHS] and LAC+USC pharmacy follow the CHS Pharmacy Policy and Procedure Manual with regard to the use of medi-cations in the Public Health Centers. This Manual also provides a formulary

of medications that are stocked or that can be special-ordered from the Pharmacy at LAC+USC. Prescriptions for outside pharmacies are usually only written for communicable disease con-trol situations in institutional settings. Additionally, the Auditor Controller mandates a system of monitoring high cost/high volume medication that is maintained under a special drug moni-toring procedure.

The HWHC Clinic Nursing Staff, under the direction of a Supervisor Clinic Nurse 1, is responsible for stocking (medications are stored in each clinic area in locked cabinets), -ordering, as-suring the integrity of the medication, administering (medications are given during clinic visits, on a walk-in basis, delivered for the purpose of directly observed therapy), maintenance of medication supplies (bi-monthly inventory for the purpose of order-ing), and inventory of high cost/high volume medications after each session in STD and TB Clinics. The LAC+USC Pharmacy is responsible for supplies, consultation, special orders, monthly inventory to ensure all drug dispens-ing meets regulated and professional standards, and bi-monthly delivery.

Since in–house dispensary services are essential to facilitating patient’s access to medications, the LAFC will support patients’ needs as follows:

• Provide patient education, drug information and interaction assess- ment through a pharmacist and/or dispensing RN.• Provide and stock basic generic medications for common ambu-

latory conditions, including family planning methods, bandages, splints, injectables, medication samples, etc.• Medications not available in the

dispensary will be available for PPP patients to have filled by an outside contracted pharmacy at no cost to patient.• Patients with Medi-Cal or other health coverage, or receiving services reimbursable by FPACT, may also receive medications at outside pharmacies with billing handled by those respective agencies.



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developing an innovative service integration model in los angeles

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