Improving Behavioral Health Through Data-Driven Collaboration A Santa Cruz County Case Study SEPTEMBER 2023 AUTHORS Jennifer Bresnick and Samuel Taylor, MSW About the Authors Contents Jennifer Bresnick is a journalist and free- lance content creator with over a decade of experience in the health IT industry. Her 3Introduction work at Inkless Creative Services focuses 3 What is BHQIP? on leveraging digital tools to create value, improve health equity, and achieve the 4 Santa Cruz County promises of the learning health system. 5 Implementing BHQIP in Santa Cruz County Supporting Payment Reform Samuel Taylor is a senior consultant in the Policy Innovation Group at Intrepid Adapting to Align with Policy Reforms Ascent. A self-described policy wonk, he Enhancing Insight into Underserved Populations has nearly a decade of experience in policy research and consulting. Samuel serves as 9 Lessons Learned from BHQIP as a Case Study in HIE Infrastructure Improvement the behavioral health policy subject matter expert at Intrepid Ascent and leads imple- Coping with Ongoing Workforce Shortages mentation of several Behavioral Health Taking a Broader View of Planning and Executing Data- Quality Improvement Program engage- Driven Projects ments with California behavioral health Navigating a Complicated Landscape of Consent and agencies. He holds a Master of Social Work Privacy Regulations with a concentration in policy and research Establishing a Neutral Convener from Washington University in St. Louis. Thinking Creatively to Ensure Health Equity 11 Key Takeaways About the Foundation The California Health Care Foundation is 12 Conclusion an independent, nonprofit philanthropy that works to improve the health care sys- 13 Endnotes tem so that all Californians have the care they need. We focus especially on making sure the system works for Californians with low incomes and for communities who have traditionally faced the greatest barri- ers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a complex system. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. Cover photo: Jessica Brandi Lifland. C alifornia is the most populous state in the Santa Cruz County, just south of San Jose, is one nation, with close to 40 million residents of the state's leaders in leveraging HIE to improve in its 58 counties. More than 15 million of care delivery for behavioral health clients. With a these people, including 4 in 10 children, one in five well-established HIE infrastructure, a clear roadmap working-age adults, and two million seniors and for health system transformation, and a strong com- people with disabilities, are eligible for Medi-Cal, mitment to change, the county has become a case the state's Medicaid program for people with low study in impactful innovation across its behavioral incomes.1 health services. Due to the scale and complexity of Medi-Cal, This paper explores how programs like BHQIP and individual counties take on a large portion of the other CalAIM initiatives can provide a framework responsibility for administering the program and for improving data-driven collaboration in county providing safety-net health care services to people health care settings, using Santa Cruz's challenges in need. While this approach makes sense for a state and successes as a guide for addressing future where the geography, economics, and population reform efforts. patterns vary widely from region to region, it can also pose challenges for creating a coordinated, What is BHQIP? equitable, and seamless health care continuum. To ensure a uniformly high-quality experience for BHQIP is a voluntary program that incentivizes Medi-Cal enrollees, the California Department of county behavioral health agencies (BHAs) to imple- Health Care Services (DHCS) has introduced CalAIM ment service delivery and administrative reforms (California Advancing and Innovating Medi-Cal): a that will improve access to behavioral health ser- long-term commitment to turning Medi-Cal into a vices, simplify how these services are funded, and person-centered, holistic health care delivery sys- catalyze the administrative integration of mental tem. The overall CalAIM initiative is made up of a health and substance use disorder (SUD) treatment. series of programs involving county Medi-Cal stake- The program combines payment reforms and pol- holders, including the Behavioral Health Quality icy changes with a sharp focus on leveraging data Improvement Program (BHQIP). exchange to better coordinate care for people with behavioral health needs. Robust, seamless, and compliant health information exchange (HIE) is at the heart of CalAIM's goals. Every participating county BHA will complete a From offering insight into population health risks to series of milestones in three distinct goal areas: enabling timely follow-up on referrals for housing payment reform, behavioral health policy changes, or other social needs, HIE is crucial for supporting and data exchange capacity building (see Table 1). appropriate allocations of resources, smooth transi- tions of care, and successful coordination between providers. Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 3 Table 1. Milestones for Participating in the Behavioral Health Quality Improvement Program GOAL 1: PAYMENT REFORM $ Milestone 1a: Implement new Current Procedural Terminology or Healthcare Common Procedure Coding System codes, modifiers, place of service codes, and taxonomy codes. $ Milestone 1b: Update county reimbursement claims processing systems and successfully submit electronic claims for encounters, known as "837 transactions." $ Milestone 1c: Implement a new Intergovernmental Transfer agreement protocol with the Department of Health Care Services to pay for certain outpatient behavioral health services. GOAL 2: BEHAVIORAL HEALTH POLICY CHANGES $ Milestone 2a: Implement new standardized screening tools for youth and adult enrollees. $ Milestone 2b: Implement a new standardized transition of care tool for enrollees who need more or fewer behavioral health services. $ Milestone 2c: For behavioral health agencies that participate in the Drug Medi-Cal Organization Delivery​System, implement ASAM criteria to determine level of care. $ Milestone 2d: Implement revised documentation standards, including but not limited to assessment domains, problem lists, progress notes, and applicable timeliness standards. $ Milestone 2e: Provide guidance and training to county-operated and county-contracted providers on all new behav- ioral health policies. GOAL 3: DATA EXCHANGE CAPACITY BUILDING $ Milestone 3a has two options: • Option 1: Demonstrate direct sharing of data with managed care plans. • Option 2: Demonstrate onboarding to a Health Information Exchange. $ Milestone 3b: Demonstrate an active Fast Healthcare Interoperability Resources application programming interface to comply with Centers for Medicare & Medicaid Services mandated interoperability rules. $ Milestone 3c: Demonstrate that the participating entity has mapped data elements to the United States Core Data for Interoperability standard set. $ Milestone 3d: Leverage improved data exchange capabilities to improve quality and coordination of care. Sources: "CPT® overview and code approval," American Medical Association (AMA); "Healthcare Common Procedure Coding System (HCPCS)," AMA; CalAIM Behavioral Health Payment Reform: Intergovernmental Transfer (IGT) Frequently Asked Questions (FAQs) (PDF), Department of Health Care Services (DHCS), February 2023; Youth Screening Tool for Medi-Cal Mental Health Services (PDF), DHCS, January 2023; Adult Screening Tool for Medi-Cal Mental Health Services (PDF), DHCS, January 2023; "Drug Medi-Cal Overview," DHCS, Last modified March 23, 2023; "About the ASAM Criteria," American Society of Addiction Medicine (ASAM); Michelle Baass, DHCS, Behavioral Health Information Notice No: 22-019, April 22, 2022; The FHIR® API (PDF), Office of the National Coordinator for Health Information Technology (ONC); "Interoperability and Patient Access Fact Sheet," Centers for Medicare & Medicaid Services (CMS) Newsroom, March 9, 2020; "United States Core Data for Interoperability (USCDI)," ONC. Santa Cruz County The Santa Cruz County Health Services Agency (HSA) has been actively involved in data-driven Santa Cruz County lies at the northern end of health system reform. The county launched its five- Monterey Bay. While it is California's second-small- year Strategic Plan in 2020 and has developed a est county by land area, it is home to more than collaborative data strategy to align data gover- 264,000 residents and sees many more traverse the nance and data management activities across region on their way to and from Silicon Valley to the county stakeholders.2 Overall goals include expand- north and Monterey County directly to the south. ing access to public health data for epidemiology and population health management, developing California Health Care Foundation www.chcf.org 4 formal data-sharing agreements with relevant par- With teams assembled, leaders could envision how ties, and preparing for upcoming statewide HIE BHQIP's goals would contribute to the larger data projects, such as the Health and Human Services exchange ecosystem and begin to develop action Data Exchange Framework (DxF). plans for individual milestones. Santa Cruz County participated in California's Whole Person Care (WPC) Pilots, which ran from 2016 to Supporting Payment Reform 2020. Santa Cruz's WPC Pilot focused mainly on Under Goal 1 of the program, participating coun- connecting unhoused people with serious behav- ties are required to upgrade their coding and ioral health or SUD treatment needs with resources claiming systems and modify their existing reim- to help them access housing and appropriate care. bursement structures for behavioral health services. To do so, the County had to establish data shar- These payment reforms are designed to standard- ing agreements and HIE pipelines with a variety of ize statewide reporting of behavioral health service stakeholders, including public health entities, county utilization from DHCS to Centers for Medicare & public safety and criminal justice departments, the Medicaid Services and move county BHAs to a fee- county housing authority, health system partners, for-service model for reimbursement, which DHCS payers, and community-based organizations provid- argues will simplify payments and incentivize pro- ing social and non-medical services. viders to deliver value-based care.3 The county decided to participate in BHQIP to The milestones in this section include implement- further augment its efforts to foster data-driven ing new Current Procedural Terminology (CPT) or care across all its departments and health system Healthcare Common Procedure Coding System partners. (HCPCS) codes, updating county claiming sys- tems and successfully submitting electronic 837 transactions, and implementing a new method for Implementing BHQIP in Intergovernmental Transfer (IGT) agreement proto- cols. These reforms are largely administrative and Santa Cruz County are not designed to directly address the exchange of patient information. However, they do indirectly Launching BHQIP required Santa Cruz to assemble support other CalAIM-related data sharing and a team of subject matter experts across the three quality improvement goals by modernizing a his- main goal areas to oversee the completion of each torically burdensome system. required milestone, including stakeholders from bill- ing and quality improvement, leaders from Drug Previously, many BHAs in California developed Medi-Cal Organized Delivery System (DMC-ODS) and used their own set of service codes to bill for and managed care plans (MCPs) providing non- behavioral health services. With the adoption of specialty mental health services, representatives standardized CPT and HCPCS codes, BHAs can from Santa Cruz Health Information Organization enhance data-driven decision making with a more (SCHIO), as well as heavy users of Netsmart's myA- detailed look at service utilization. Adopting stan- vatar, the county HSA's behavioral health electronic dardized codes also aligns BHAs with other health health record (EHR). systems and organizations that currently use the CPT and HCPCS code to bill for services. Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 5 Adapting to Align with Policy "This is an important effort for coordinating care. Reforms But what's not included in this goal is the creation of a step-down tool for people who no longer need Goal 2 of BHQIP centers on behavioral health the same intensity of care," said Subé Robertson, policy changes that aim to improve access to per- Director of Quality Improvement at Santa Cruz sonalized, timely care for enrollees. Key milestones Behavioral Health Services. "In the future, I would include: like to see counties required to prove that they have a plan for stepping people down from treatment $ Developing and implementing a standardized and the standardized tools for documenting those screening tool for clinician use to determine transitions in an organized way." the correct delivery system and initial level of care for behavioral health services, as well as a standardized transition tool for transitioning Enhancing Insight into Underserved enrollees to a lower or higher level of care Populations $ Implementing revised documentation Unlike many other counties, Santa Cruz has a unique standards in a number of areas, including partner that helps the county improve and deploy assessment domains, problem lists, progress HIE activities. For the past 20 years, the Santa notes, and applicable timeliness standards Cruz Health Information Organization (SCHIO) has $ Providing guidance and training to county- worked to enable bidirectional data exchange for operated and county-contracted provider hundreds of providers, develop community-wide organizations on all new behavioral health longitudinal health records, and connect to larger policies HIE networks such as eHealth Exchange.4 In line with CalAIM's broader data sharing objectives, "We are firmly committed to being a health data util- Santa Cruz needed to make several improvements ity and a single source of truth for the region while to their behavioral health EHR to achieve Goal 2 helping providers and county leaders navigate the milestones. The county's quality improvement team tricky landscape of consent and privacy that governs worked closely with providers and technical staff to data exchange," said SCHIO Executive Director develop draft templates for documentation stan- Dan Chavez. "The rapport we have with the county, dards (e.g., problem lists, progress notes). along with the trust and value we've built over the past twenty years, are incredibly important when The county repeated this process when DHCS embarking on improvement projects like these." released the final standardized templates for screening and transition tools in January 2023, "We also have a very long lasting, strong relation- establishing a workgroup to refine and then imple- ship with the managed care plan in Santa Cruz ment electronic versions of these tools within their County, which is the Central California Alliance for EHR that integrated with an enrollee's record. These Health. Being a partner for both entities sets up the tools will help to streamline completion of the county to work effectively as a team and take advan- assessments and facilitate closed-loop communica- tage of what we want to do with WPC, BHQIP, and tion with subcontracted providers and MCPs. Cal-AIM in general," Chavez said. Santa Cruz's established partnership with SCHIO gave the county a jumpstart on Goal 3, which California Health Care Foundation www.chcf.org 6 addresses data exchange infrastructure improve- "This is a big step forward in sharing behavioral ments. Because the behavioral health system was health data because we are no longer limited to the already connected to SCHIO, the County could standard admission, discharge, and transfer (ADT) easily check off Milestone 3a simply by demonstrat- feeds that only provide limited information on a ing that the connection exists and is functional. person's activities. By enabling access to everything in a CCD, we can include important details that will What's more, county leaders are working with help care teams make more informed decisions SCHIO to use Health Level 7 International (HL7), about what happens next with that person," Dillon which enables more a seamless exchange of continued. Continuity of Care Documents (CCDs), ensuring critical clinical information is available when and Standardized connections are also the focus of where it is needed.5 Milestone 3b, which requires the implementation of an HL7 Fast Healthcare Interoperability Resources "CCDs are standardized documents, but there can (FHIR) application programming interface into the be different architecture for sending or receiving EHR. This API isn't only a BHQIP bullet point: access these documents on either end of a transaction," to an HL7 FHIR API is a requirement for all 2015 said Brian Dillon, Technology Strategy Consultant Edition Certified EHRs as of December 2022.6 at Intrepid Ascent. "There has to be some sort of conversation around how these documents will be The capability is intended to enable the exchange received - and more importantly, how both parties of crucial health information "without special effort" are going to identify the patient correctly and be on the part of either the sender or the recipient, sure that the right information is being associated according to the Office of the National Coordinator with the right individual every time." (ONC). As of August 2022, approximately two-thirds of inpatient users and 77 percent of ambulatory Patient matching is a perennial concern in data users nationwide had access to ONC-approved API exchange and can be particularly challenging when functionality through their EHR vendors.7 coordinating care for populations that may not have standard demographic identifiers, such as a per- But access to a function and active use of that tool manent address, social security number, or phone are two different things. While a majority of EHR number. In addition, Medi-Cal members often enter users nationally have the technical ability to use and leave the program at unpredictable intervals, such an API to transmit data, thus meeting the basic and may not consistently engage with providers. mandate, very few have yet to make use of them. BHQIP goes one step beyond the national pro- "It's difficult to decide when to close out a patient, gram by requiring that participants create active, especially without a separate data field that indi- workable connections through the API to send and cates whether the person is active or not," said receive real, meaningful data. Dillon. "We are addressing this by exchanging a monthly patient roster that uses evidence of a In Santa Cruz, the FHIR API became operational recent encounter to indicate whether a person is on March 1, 2023. While county agencies are not currently active. That creates a monthly working yet sending or receiving data through this pipeline, population to manage, and makes it easier to add SCHIO is already an active user. By the fall of 2023, or drop records and update the information that SCHIO plans to begin using the API to identify needs updating." and close gaps in client data that is already being Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 7 exchanged across the county. Using the API will add and responsive care to Latinos/x and primarily flexibility to the County's technical infrastructure Spanish-speaking people. and ensure that important data is being exchanged appropriately to support care. Part of the solution lies in increasing the availabil- ity of Spanish-speaking translators, care navigators, Milestone 3d, the final component of BHQIP, and clinicians who can assist people who feel more requires that counties leverage improved data comfortable communicating in Spanish. Meanwhile, exchange capabilities to improve quality and coor- the technical component of the solution centers on dination of care across three use cases: bidirectional data exchange. County behavioral health providers can already receive notifications $ Follow-up after an emergency department that one of their clients has recently visited the visit for alcohol and other drug abuse or emergency department. A new referral transmis- dependence sion and tracking system will enhance these insights by sending DMC-ODS referrals and discharge infor- $ Follow-up after emergency department visit mation to both the county behavioral health system for mental illness and hospital substance use navigators (SUNs). $ Pharmacotherapy for opioid use disorder Ideally, the system will also notify SUNs when an initial appointment has been made with the appro- As well, Santa Cruz created a performance improve- priate treatment provider. ment plan for each use case with the assistance of Praxis Associates to guide technical and workflow The county is also working with SCHIO to produce development activities in pursuit of these criteria. For daily reports on all enrollees admitted to the emer- example, the county recognized that most patients gency department, which would include discharge with SUD and mental illness-related visits to the ED information enabling the department to follow were not getting appropriate follow-up care, with up on people when appropriate. These data will particularly significant disparities among Spanish- be compiled into detailed monthly and quarterly speaking people and those identifying as Latino/x. reports for data monitoring purposes to support continuous improvement in this area. To remedy the issue, the county assembled a weekly workgroup of stakeholders from senior "This was a challenging area to solve for, because management, IT, clinical care, and quality improve- no solution is ever purely technical or purely admin- ment. They also consulted with members of the istrative," said Jennifer Susskind, MCP, Lead Planner Santa Cruz County Mental Health Advisory Board, and Evaluator from Praxis Associates. "It will always which provides oversight and monitoring of local take a combination of education and awareness for mental health and substance use services and is the front-line clinicians, improvements to the data comprised largely of people who identify as con- we need to monitor performance, and upgrades to sumers of behavioral health services themselves. bidirectional data exchange capabilities to develop The teams uncovered several root causes for the new workflows that have a direct impact on how cli- lack of appropriate follow-up, including confusion ents receive care." among providers as to the correct referral path- way; the use of "informal" referrals that are not actionable for tracking follow-up; and insufficient resources and knowledge to provide culturally-safe California Health Care Foundation www.chcf.org 8 Lessons Learned from too, and that we can start to see results trickle down to our clients if we really work at it." BHQIP as a Case Study in HIE Infrastructure Taking a Broader View of Planning Improvement and Executing Data-Driven Projects Widespread staffing shortages mean that Santa Cruz Coping with Ongoing Workforce has been working with approximately 30% of its posi- Shortages tions unfilled, leading to major gaps in the necessary skill sets to make headway on CalAIM goals. CalAIM is a years-long, multi-part initiative with plans to keep launching new improvement proj- "I don't have a health information management ects through 2027.8 For county health leaders, this (HIM) manager at the Health Services Agency, means a continuous series of challenges that will and we don't have one in behavioral health," said test their abilities to rally scarce resources, main- Tiffany Cantrell-Warren, Santa Cruz County Director tain motivation among stakeholders, and manage of Behavioral Health. "If we had people in those data efficiently and effectively to provide actionable types of positions two years ago, we would have insights for improved patient care. been able to develop a more comprehensive stra- tegic vision for BHQIP and a plan to get there Uneven guidance from state authorities on tech- much more quickly. It's basically been different divi- nical and administrative requirements paired with sion directors, like myself, pulling these projects tight and shifting deadlines sometimes leads to together amongst all our other responsibilities, and guesswork and quick decisions that may or may there's only so much we can do with our limited not align with what CalAIM's architects envisioned. bandwidth." These circumstances can lead to dampened enthu- siasm for programs like BHQIP. Before the next round of quality improvement proj- ects hit, Cantrell-Warren suggests counties try to "Everyone's plates are overflowing, which makes it secure an experienced data strategist who can take tough to feel as if these initiatives are sustainable," a bird's eye view of the problems at hand. Investing acknowledged Robertson. "We're expected to in this type of role could allow counties to work make change upon change in a really short time- more effectively with limited staff and provide more frame without the staff we need to make [those clarity and certainty around what is expected of changes] happen, which doesn't feel great when we each contributor. come into work every day bringing our best." "There is so much duplication of systems and data Robertson continued, "But on the other hand, sets in our county, and I'm sure in other counties, as sometimes you need pressure to shift perspectives. well," she said. "The hardware people are thinking People are starting to realize that these activities about hardware, and the software people are think- don't just live in the quality improvement depart- ing about software, but no one is really overseeing ment. They affect everyone, and they could bring both. We need someone who can understand positive changes to everyone, if we all get involved. what we have, envision how they should all work I'm seeing more understanding at the clinical team together, and direct the necessary changes so that level that they have responsibility for these tasks, we're meeting our objectives efficiently." Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 9 Navigating a Complicated hurdles as they work to exchange health informa- Landscape of Consent and Privacy tion across entrenched barriers. Regulations "At the start, we thought BHQIP would help us clear Meeting the technical goals of BHQIP requires up some of the legal questions we had and give us participants to first hash out answers to many long- a state-approved framework for sharing informa- standing questions about privacy and consent in tion. But that hasn't happened to the degree that the behavioral health space, such as how to appro- we need," said Cantrell-Warren. "I'm still fielding priately share SUD data that is subject to federal questions about which federal laws supersede state confidentiality restrictions.9 laws and vice versa, and our stakeholders are strug- gling to come up with acceptable answers." "We have a network of federal and state regula- tions that are designed to empower behavioral The result is unintentional data blocking, noted health clients and prevent bias in their care and representatives from SCHIO, since certain highly their daily lives, but they don't always align with restricted information doesn't flow through to the each other in a way that allows clinicians to view HIE at all. "We need to change the regulations and their clients as whole people," explained Cantrell- change how things are being done if we are truly Warren. "Many of these regulations come from a going to achieve whole person care," said Becky place of stigma and outdated thinking on SUD as Shoemaker, senior project manager. "The state a moral failing instead of a health condition, which could do a better job of relaying information and needs to change." putting mandates in place that would allow partici- pants to feel comfortable with sharing information "Voters and legislators are responsible for mak- appropriately." ing that happen. As public servants, however, it's our job to find ways to treat people the best we "It would certainly help counties with these pilots can within the existing regulations and design our because the attitude right now is that they cannot technical infrastructure to facilitate compliant data afford to take any risk, so they're erring on the side sharing wherever possible so that clinicians can of not sharing at all. That's not going to work for the make informed decisions," she said. long term. We invite state leaders to take a more collaborative role in these improvement efforts on This lack of transparency can also be dangerous. a granular level so that we can meet their expecta- "When you go to school as a clinician, you are very tions without preventable missteps." strictly told not to share information with pretty much anyone," said Robertson. "Many times, that's interpreted as not being able to share even with Establishing a Neutral Convener other members of the patient's care team, which SCHIO has been an important asset to Santa Cruz's isn't always true and can even bring harm to the data transformation efforts, not just because of the patient when something like contraindicated medi- technical infrastructure the organization has built cations are involved." and overseen, but also because it acts as a neutral party when county and state stakeholders come In Santa Cruz, BHQIP has shed light these concerns, together to make decisions about workflows and as program participants continue to encounter legal business agreements. California Health Care Foundation www.chcf.org 10 "Everyone has their own interests to fight for. Whether we like it or not, access to data often KEY TAKEAWAYS becomes collateral in those conversations," said $ Workforce shortages aren't going away any Cantrell-Warren. "If you have an HIE that isn't led time soon, meaning leaders have to be both by the county, and its driving mission is to facili- proactive and realistic about what they can tate data exchange to everyone equally, it offers accomplish. To secure engagement and avoid burnout, be sure to educate staff about the opportunity to have an objective opinion and a how programs like CalAIM and BHQIP will mediator when necessary." positively impact health care clients. Be clear about connecting the dots between specific "We've been fortunate to have SCHIO in that role. workflow changes and their intended down- I would advise other counties to find an entity that stream effects. can serve that purpose in their environment. It can $ Coordination is key for success with a large, make a significant difference in how difficult conver- complex project like CalAIM. Think about sations play out and help everyone get to a shared creating a county-wide data strategy role solution quicker," she said. that focuses on identifying how all the mov- ing pieces should come together. This role doesn't have to be overly technical, but Thinking Creatively to Ensure Health should act as a unifying, motivating force for Equity understanding and executing on state objec- Medi-Cal covers more than a third of California's tives. population, and almost none of those people $ Making sense of privacy rules can be spend their entire lives within the confines of a extremely challenging, especially when state single county. Whether they have no fixed address, and federal regulations are both in play. travel for work, seek care in multiple health systems, While major policy changes may be out of a county's control, leaders should urge state- or visit family elsewhere in the state, patients don't level officials to provide more guidance and respect arbitrary county borders the way adminis- meaningful resources to help clarify local and trators do. national laws. $ Counties are useful administrative units in a "Our federated model has its strengths, but we state as large as California, but clients don't also have to address the weaknesses and potential always stay within a single county's borders disparities that can occur when we only look inter- when seeking care. Leaders need to work nally all the time," said Chavez. "There isn't enough with their neighboring counties to under- recognition that people will generally do what is stand how to share data appropriately across convenient and gives them immediate satisfaction, county lines and how to provide mutual aid and those things rarely align with our ideal vision of in larger health system transformation goals. what the health system should look like." "As hard as it is to develop HIE within a county, we have to do a much better job of creating cross- county data exchange so that we can support these individuals no matter where they are in California. That will require better patient matching infrastruc- ture, timely eligibility checks for people going on Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 11 and off Medi-Cal, and more robust intracounty data have value far beyond the specifics of any single sharing agreements," he continued. improvement program. And the results are already evident in qualitative ways. Chavez encouraged state and local leaders to apply lessons learned from Medi-Cal improvement initia- "I've seen big changes in how teams are working tives to the broader health care environment in an together across different functions," said Cantrell- effort to ensure equity in care delivery across popu- Warren. "I've seen a lot more engagement with the lation sectors. quality improvement team from people in admin- istrative and EHR development, service delivery, "We don't want to reinforce inequities that we saw psychiatry, children's behavioral health, and SUD. during the pandemic, and we certainly don't want They want to get involved in what these workflows to create new ones," he said. "Taking a close look at look like, because now they know that there's no improving care for a focused population like Medi- such thing as a data question, or a QI question, Cal SUD and behavioral health clients is important, or an EHR question. Everything is connected, and but we have to remember to roll up those learnings we're starting to acknowledge that much more to other communities at risk so we can improve care clearly now." and outcomes for everyone." However, there is still significant room to improve both the design of CalAIM's programs and the man- Conclusion ner in which county-level stakeholders complete their objectives. Over the next several years, state Santa Cruz County has been committed and suc- leaders will need to work more closely with county cessful in its pursuit of BHQIP's goals, in large part officials to define the parameters for health infor- because leaders have made a point of treating the mation exchange and provide additional guidance program as a jumping off point for HIE improve- on how to meet program goals within the unique ments that will have positive downstream impacts context of each county's capabilities and priorities. on patient care. If participants can gain the necessary clarity and BHQIP is an ambitious and multifaceted program, direction - and obtain the staffing resources to sup- but it offers a valuable opportunity for counties to port continuous improvement - health information address common gaps in their workflows and infra- exchange will continue on the path to becoming a structure. "BHQIP is helpful for providing structure, powerful tool for achieving CalAIM's vision of deliv- accountability, and financial support to focus our ering high-quality, accessible, equitable health care attention on tasks that we might not otherwise be to all Californians. able to prioritize," said Robertson. "It also helps us align our objectives and strategies across our vari- ous HSA agencies. It's prompted us to start looking at our strengths and weaknesses, such as where we need more resources or more learning to shore up our capabilities." As well, BHQIP offers participating counties a way to meet defined targets in data exchange that California Health Care Foundation www.chcf.org 12 Endnotes 1. Medi-Cal Monthly Eligible Fast Facts (PDF), California Department of Health Care Services (DHCS), February 2023. 2. Santa Cruz County Health Services Agency 2025 Strategic Plan (PDF), Santa Cruz County Health Services Agency (HSA), September 2020; "County Strategic Plan," Data Share Santa Cruz County. 3. California Advancing and Innovating Medi-Cal (CalAIM) Overview: Behavioral Health Payment Reform (PDF), DHCS, December 2022. 4. "What we do," eHealth Exchange. 5. "About HL7," HL7 International. 6. "Certification Criteria," ONC, last reviewed March 10, 2022. 7. Jennifer Bresnick, "Vendor alert: API deadline looms for Certified EHRs," DHI Insights, November 14, 2022. 8. CalAIM Initiatives Launch Timeline as of February 2023 (PDF), DHCS, February 2023. 9. "Part 2 – Confidentiality of Substance Use Disorder Patient Records," Code of Federal Regulations, Title 42, January 18, 2017. Improving Behavioral Health Through Data-Driven Collaboration www.chcf.org 13