May 2012, by Annette Gardner, PhD, MPH. A report of the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, and the Center for Labor Research and Education, University of California, Berkeley.

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ABSTRACT
The Patient Protection and Affordable Care Act (ACA) provides an opportunity to coordinate care among health care providers and transform local safety nets into seamless systems of care. Dr. Gardner’s study of safety net integration activities in five California counties—Contra Costa, Humboldt, San Diego, San Joaquin, and San Mateo—confirmed that these counties had already made a great deal of progress. Each county is focusing on systems-wide integration, cross-provider integration, and patient-level integration. In addition, there is evidence that many of these integration initiatives have increased coordination of care and strengthened partnerships between providers and county agencies, thereby facilitating implementation of health care reform. Though there are differences in capacity and in the resources counties bring to bear, the study nonetheless identified specific strategies and models that can be adopted by other counties, particularly in the areas of specialty care access, mental health and primary care integration, patient care coordination, and outreach and enrollment. This report describes the factors that affect the ability of a local safety net system to develop integrated delivery systems. It also discusses lessons learned from the implementation of 30 safety net integration "best practices" that can be applied to other counties.

EXECUTIVE SUMMARY
The Patient Protection and Affordable Care Act (ACA) provides an opportunity to transform local health care safety nets into seamless systems of care. An assessment of safety net integration activities underway in five study counties—Contra Costa, Humboldt, San Diego, San Joaquin, and San Mateo—suggests much progress has been made to this end. All are focusing on systems-wide integration (e.g., launch of their Medi-Cal Waiver Low Income Health Programs), cross-provider integration (e.g., mental health and primary care integration, e-referral systems), and patient-level integration (e.g., Nurse Advice lines, Certified Application Assistors). Most are considering Accountable Care Organizations (ACOs), consumer ePortals, and Health Information Exchanges (HIE). In addition to undertaking diverse integration initiatives, their information technology (IT) infrastructures continue to evolve albeit in a piecemeal fashion. There is evidence that many of these initiatives are resulting in coordinated care and strengthened partnerships between providers and county agencies, facilitating implementation of health care reform. Though there are differences in capacity and the resources that counties bring to bear, there are specific strategies and models that can be adopted by others, particularly in the areas of specialty care access, mental health and primary care integration, patient care coordination, and outreach and enrollment.

The comparison of five counties that have made great strides toward creating integrated delivery systems corroborates earlier UCSF findings that great capacity and willingness to reengineer health care for the medically underserved resides at the county level. These counties have the partnerships and shared commitment to create seamless systems of care. The presence of safety net collaboratives and/or nimble organizations, such as Medi-Cal managed care organizations and clinic consortia, afford counties the ability to secure resources and implement integration initiatives individual stakeholders might not otherwise undertake. The analysis of the 30 safety net integration “best practices” points to several common factors for success, including leadership support at the top, shared leadership among organizations, perseverance of effort, open communications, and buy-in at all levels.

However, delivery system gaps and financial challenges loom large. Funding for these efforts varies by safety net stakeholder, and is piecemeal and project driven. While the high capacity to meet the needs of the newly insured and remaining uninsured bodes well for continued progress in all five counties, these counties nonetheless face significant challenges, be it the erosion of county funding or gaps in access to primary care. Key strategies to expand safety net integration include targeted support for some types of integration activities (e.g., safety net ACOs), IT infrastructure, and broadbased networks, as well as state policymaking that is sensitive to county safety net variation and leverages ACA provisions and policies to support integration (e.g., the Health Benefit Exchange).

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