Safety Net Partners: Collaborating to Create and Support Person-Centered Health Homes to Address the Needs of High Risk Community Members

National health reform has renewed attention and focus to supporting innovation in the health care delivery system. Health plans, health care organizations, and providers are rapidly shifting from “usual care” to implementing new solutions, including implementing person-centered health homes (PCHH).  Transformation of the health care delivery system and clinical practices requires complex redesign to achieve health reform’s Triple Aim of improved population health outcomes, enhanced patient experience, and lowered overall costs of care.  Under the ACA, health care coverage has expanded to a broader population, including people with complex, high cost health care needs, who can benefit from improved care coordination and comprehensive case management.  

 This session presents key findings from the evaluation of California’s Health Home Innovation Fund (HHIF). The HHIF Initiative funded 8 multi-stakeholder, regional collaboratives across California to improve care coordination and integration among safety net institutions and providers to better serve patients, particularly those with complex needs. Collaboratives involved a range of stakeholders, including regional clinic consortia, health plans, community health centers, behavioral health organizations, hospitals, and community-based organizations. The HHIF evaluation used a mixed method, participatory approach to examine the implementation experiences and outcomes achieved across the funded collaboratives. 

 This session presents key learnings about the PCHH transformation process, including: the role of clinic consortia and managed care organization in facilitating health home transformation; fostering strong cross-sector partnerships in the community to serve complex populations, barriers and facilitators to practice and system transformation; and recommendations to sustain and advance community health home efforts.