Upstreamists in Action: Upstreamists are changemakers pioneering practices that improve health by blending medical and social care. In this series of profiles, HealthBegins highlights some of these bold leaders and their innovations, in settings large and small. Their stories show us that the journey upstream is not only necessary — it’s possible.

Advice for other upstreamists:
“Always ask. Come into the exam room with a curiosity about your patient as a fellow human being. Consider ‘success’ as a medical team to be an open, respectful, and trusting relationship with another human, not a lab value or biometric reading ‘at target.’ Be curious as to what in a person’s life might be contributing to their struggles, and allow that to drive your conversation and ultimately the plan developed by the medical team.”

Dr. Sayles’s story: 
When Jennifer Sayles meets a patient, she starts by asking some unconventional questions: Where are you staying? Do you have enough food? How do you get around? Do you have close friends or family? How is your life going?

Those issues come before any checks of physical health, because stability in everyday life is the necessary foundation for any physical healing. Dr. Sayles knows this from her earlier work with HIV patients in the Los Angeles safety net.

With HIV, she learned, “You have extraordinarily effective treatment, but the things that influence patients’ health behavior and their ability to participate in their treatment aren’t really about me picking the right drug. They’re about what their life has been like.”

Now Sayles is trying to bring that more-than-medical mindset—and the greater healing it can enable—to dozens of clinics across California’s Riverside and San Bernardino counties.

When she arrived as chief medical officer at the Inland Empire Health Plan (IEHP) in June 2016, the effort was already under way. Her predecessor, Peter Currie, had launched a pilot program to transform care-as-usual in the Medi-Cal health plan’s network—to make behavioral health an integral part of the approach to medicine. Now Sayles is sustaining that effort and working to expand IEHP’s definition of medicine still further, into stable housing and beyond.

The program has already demonstrated what’s possible when teams of caregivers work together to create and follow a care plan that takes a patient’s complete medical and behavioral needs into account. IEHP created the new approach in stages.

First, the health plan chose 31 of its hundreds of care sites that were ready and eager to try something new. With $35 million in total funding from IEHP, each site hired new staff to create a complex-care team: a complex care manager (either an RN or an LCSW), a care coordinator to handle outreach and referrals, and a behavioral health clinician.

It wasn’t enough to build “a co-located model were people work down the hall from each other but never really talk to each other,” or one where you just shuffle notes back and forth from one service to the other, Sayles explains. The services had to be truly integrated—just as a patient’s needs are.

Each care team began by partnering with one or two physicians on site who were most interested in this work. They started with the highest-risk patients, those who suffered from multiple physical and behavioral conditions. And they provided new kinds of services that those patients and their communities had never had before, such as community outreach, individualized health education, expanded screening to spot a more complete set of patient needs, and connections to other agencies for any services the team itself couldn’t provide. At the heart of this work was a shared care plan, followed by the whole team and created with the patient’s own goals in mind.

Practice coaches still visit each site regularly to support this evolution. By the end of 2018, Sayles expects to have community health workers integrated into the care teams at all 31 sites, helping patients navigate the services provided by IEHP’s community partners. IEHP also created a new data system, which the teams use to track how individuals and whole communities of patients are faring. Now they can see visually how often patients’ various conditions—conditions once treated as separate, such as high blood pressure and depression—rise and fall together.

The results are promising. In the first months of the project, patients’ average blood glucose levels declined from 9.4 to 9.1 HbA1c; average systolic blood pressure dropped from 152 to 135; and depression scores on the PHQ-9 measure went down from 17 to 12—even as the overall cost of the same patients’ care slightly declined.

With that complex-care initiative well under way, Sayles and her colleagues are turning their attention to housing. IEHP has teamed up with the Institute on Aging and housing provider Brilliant Corners to start moving the first of 350 homeless patients into permanent supportive housing with wraparound services. Some of these patients have chronic health conditions, while others have been languishing in long-term care without another adequate place to go. It takes money up front to make the shift, but IEHP expects improved outcomes for patients and cost savings in time.

“We have all these labels: mental health, behavioral health, substance abuse, social determinants of health,” says Sayles. “They all end up being one person.”

Sayles also aims to expand this effort to more clinics and a wider range of patients, moving beyond mental health and housing to address more of the everyday living conditions that affect people’s health. In doing so, she has enlisted HealthBegins to assist as IEHP brings these separate efforts together in a broader strategy to align programs and data to improve population health and equity in the Inland Empire.

Making that sustainable, of course, requires money. IEHP has kept funding the effort since the initial $20 million investment ran out, and it intends to continue until funding through California’s Health Homes program arrives in 2019. Sustainability also hinges on IEHP shifting its payment structure, which it is doing now—moving clinics from billing against grants to a more flexible case-rate system.

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“I’m a realist,” says Sayles. “In five years, if we had 30 to 40 really integrated, whole-person-centered medical homes in our network that were well equipped and able to take care of the high-risk patient with complex needs, that had figured out how to integrate the health workers and address these issues that get in the way of life, that would be huge. If we start to grow some of those, it will spread.”
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