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Adoption of High Value Care – Pilot Charter

Preserving Specialty Care Through County-Wide E-Consult First

County-wide initiative in Sonoma County to preserve access to specialty care for Medicaid members. Working collaboratively across health plans, Federally Qualified Health Centers (FQHCs), and hospitals to ensure the use of e-consult first, with referral to in-person specialty only if determined by e-consult. Pilot works collaboratively with plans, FQHCs, and hospitals to leverage the best practicesof health centers and networks that have already developed promising practices. This initiative explores the ability of health center coalitions or networks to act collectively to change health system outcomes at a regional level.

Background

Limited specialty access is a concern across all demographics and payors, with limited specialty and primary care access,
specialty network limitations, inadequate fee-for-service payments, cumbersome administrative processes, and a lack of
management for complex patients as contributing factors. For patients served in the safety-net, geographic isolation, uninsured
or underinsured status, and racial/ethnic minorities are additional factors. According to the 2024 DHCS Wait Times standards
report, adult MediCal patients in Sonoma County are seen within the standard 15 days for non-urgent referrals only 41.6% of the
time, and within 4 days for urgent referrals only 20.4% of the time.

In Sonoma County, Providence Medical Network provides most of the in-person specialty care. With inadequate fee-for-service
payments, high no-show rates, and inadequate clinical work-up before the visit, senior leadership expressed strong concern
about being able to continue serving Medi-Cal patients moving forward.

Proposal

County-wide initiative in Sonoma County to preserve access to specialty care for Medicaid members. Working collaboratively
across health plans, Federally Qualified Health Centers (FQHCs), and hospitals to ensure patients have an e-consult first, with
referral to in-person specialty only if determined by e-consult. Pilot works collaboratively with plans, FQHCs, and hospitals to
leverage the best practices of health centers and networks that have already developed similar referral protocols. This initiative
examines the capacity of health center coalitions or networks to collaborate and influence regional health system outcomes.

In 2024, all of the Federally Qualified Health Centers (FQHCs) in Sonoma County, which serve over 90 percent of the enrolled
Medi-Cal patients in the county, Partnership Health Plan, the primary Medi-Cal Managed Care Organization, and Providence
Medical Network, which provides most of the Medi-Cal specialty care, created a working group to explore options for preserving specialty access in Sonoma County. Based on the success of an e-consult first specialty care referral process in rural northern California, the working group agreed to adopt a referral guideline in which FQHCs would generate an e-consult before in-person or virtual specialty referral. If the result of the e-consult recommends an in-person specialty consultation, Providence Medical Network would prioritize that referral for timely access. Based on membership referral data from the Partnership Health Plan of California’s Aliados Health Network, as well as wait time analytics, usage trends, and input from health center clinical leadership, the following specialties were identified as requiring an e-consult before in-person referral: 1. Rheumatology 2. Endocrinology 3. Neurology 4. Gastroenterology. Other commonly referred and high-wait specialties may also be considered for e-consult first implementation, depending on network capacity and patient needs. Partnership Health Plan agrees to pay for e-consults and virtual specialty care for all Medi-Cal members. Aliados Health Network added a quality incentive for health center compliance with this referral to support change management
and adoption.

Phase I: Establish Multistakeholder Working Group (January – June 2025)

Develop shared referral agreements and e-consult protocols.
Formalize partnership and data-sharing agreements.

Phase II: Implement e-consult First Referral Process (July-December 2025):

Pilot with two FQHCs across selected specialties (Rheumatology, Endocrinology, Neurology, Gastroenterology).
Introduce a quality incentive for compliance.
Publish and disseminate workflow guidelines.

Phase III: Evaluate and Scale Pilot (January 2026-June 2026)

Conduct data analysis and provider/patient surveys
Expand to all Sonoma County FQHCs
Launch a participatory research initiative

Phase IV: Agreements and Sustainability Plan (July 2026-December 2026)

Review early outcomes
Secure stakeholder commitments for long-term adoption
Develop a sustainability plan.

The Impact Accelerator aims to advance the frontiers of knowledge by exploring the potential for multistakeholder networks to
implement and scale innovative solutions in the healthcare system. Specifically, the research aims to understand (1) how to
establish and sustain a collaborative network to engage in innovative efforts to improve healthcare in a health policy context; (2)
how to flexibly implement and scale solutions to urgent problems in healthcare; (3) conditions under which configurations of
solutions work best, challenges that must be overcome, and factors that enable success; and (4) how multi-sector innovation
differs if implemented at the level of the local community, county, region, and State. Using a participatory action research
approach and building on trusted relationships, investigators will collaborate with project leaders to design interventions and
investigations that balance optimal impact with generalizable learning. Rigorous methods will combine qualitative and
quantitative insights to promote replicability.

Short-Term (2025–2026):

Improved coordination between primary care and specialists.
Reduction in inappropriate or incomplete specialty referrals.
Faster turnaround time for specialty input.
Increased provider satisfaction and clinical confidence.

Medium-Term (2026–2027):

Improved patient access and experience with specialty care.
Enhanced system efficiency and reduced wait times.
Strengthened regional health equity through safety-net collaboration.

Long-Term (Beyond 2027):

Sustainable, county-wide model for equitable specialty care access.
Replicable framework for multi-sector healthcare innovation.
Evidence base for state and national scaling of high-value care models

Our Role

Convene stakeholders and coordinate activities.
Support research and measurement activities.
Project planning and communication.
Network connector, TA support, shared learning across participating organizations and partners.
Fund development.

Stakeholders

• MCOs: Partnership Health Plan
• Specialty Network: Providence Medical Network
• Safety-Net Providers: Alexander Valley Health Center, Alliance Health Center, Santa Rosa Community Health Center,
Sonoma Valley Health Center, Petaluma Health Center, West County Health Centers.
• Safety-Net Coalitions: Aliados Health Network
• Research: Stanford