Developing an innovative service integration model in Los Angeles

SPA 3 & 4 CASE STUDY
DEVELOPING AN INNOVATIVE SERVICE
INTEGRATION MODEL IN LOS ANGELES
Los Angeles County Department of Health Services • Public Health
July 2005
SPA 3 & 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES
M. RICARDO CALDERÓN, SERIES EDITOR
San Gabriel Valley and Metropolitan Service Planning Area Health Office (SPA 3 & 4)

Developing an Innovative Service Integration Model in Los Angeles : SPA 3 & 4 Case Study July 2005
SAN GABRIEL VALLEY SERVICE PLANNING AREA (SPA 3)
METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
(213) 240-8049
The Best Practice Collection is a publication of the
San Gabriel Valley (SPA 3) and Metropolitan Ser-
vice Planning Area (SPA 4). The opinions expressed
herein are those of the editor and writer(s) and do
not necessarily reflect the official position or views
of the Los Angeles County Department of Health
Services. Excerpts from this document may be
freely reproduced, quoted or translated, in part or
in full, acknowledging SPA 3 & 4 as the source.
Internet: http://www.lapublichealth.org/SPA 3
Internet: http://www.lapublichealth.org/SPA 4
LOS ANGELES COUNTY
BOARD OF SUPERVISORS
Gloria Molina, First District
Yvonne Brathwaite Burke, Second District
Zev Yaroslavsky, Third District
Don Knabe, Fourth District
Michael D. Antonovich, Fifth District
DEPARTMENT OF HEALTH SERVICES
Thomas L. Garthwaite, MD.
Director and Chief Medical Officer, Department of Health Services
Jonathan E. Fielding, MD, MPH, MBA.
Director of Public Health and County Health Officer
BEST PRACTICE COLLECTION TEAM
M. Ricardo Calderón, Series Editor
Manuscript Author & SPA 3 & 4 Area Health Officer
Cristin Mondy, MSN, MPH, CNS.
Manuscript Author & Area Nurse Manager, SPA 4
Sheree Poitier, MD.
Manuscript Author & Area Medical Director, SPA 4
Carina Lopez, MPH.
Project Manager, Information Dissemination Initiative
Photo: Courtesty of SPA 3 & 4 Area Health Office
At a Glance
The SPA 3 & 4 Best Practice Collection fulfills the Los Angeles County
Department of Health Services (DHS) local level goal to restructure and
improve health services by“establishing and effectively disseminating to
all concerned stakeholders comprehensive data and information on the
health status, health risks, and health care utilization of Angelinos and
definable subpopulations”.1
It is a program activity of the SPA 3 & 4 Infor-
mation Dissemination Initiative created with the following goals in mind:
To highlight lessons learned regarding the design, implementation,
management and evaluation of public health programs
To serve as a brief theoretical and practical reference for program
planners and managers, community leaders, government officials,
community based organizations, health care providers, policy mak-
ers and funding agencies regarding health promotion and disease
prevention and control
To share information and lessons learned in SPA 3 & 4 for community
health planning purposes including adaptation or replication in other
SPA’s, counties or states
To advocate a holistic and multidimensional approach to effectively
address gaps and disparities in order to improve the health and
well-being of populations
The SPA 3 & 4 Information Dissemination Initiative is an adaptation of the
Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collec-
tion concept. Topics will normally include the following:
1. SPA 3 4 Viewpoint: An advocacy document aimed primarily at policy
and decision-makers that outlines challenges and problems and pro-
poses options and solutions.
2. SPA 3 4 Profile: A technical overview of a topic that provides infor-
mation and data needed by public, private and personal health care
providers for program development, implementation and evaluation.
3. SPA 3 4 Case Study: A detailed real-life example of policies, strategies
or projects that provide important lessons learned in restructuring
health care delivery systems and/or improving the health and well be-
ing of populations.
4. SPA 3 4 Key Materials: A range of materials designed for educational
or training purposes with up-to-date authoritative thinking and know-
how on a topic or an example of a best practice.
2

Improving DHS Performance: SPA 4 ViewPoint Developing an Innovative Service Integration Model In Los Angeles : SPA 3 4 Case Study July 2005
3
DEVELOPING AN INNOVATIVE SERVICE INTEGRATION MODEL IN LOS ANGELES
Table of Contents
i. EXECUTIVE SUMMARY 4
I. PROJECT BACKGROUND: THE OVERVIEW 5
II. PROBLEM STATEMENT: THE CHALLENGE 6
III. PROJECT APPROACH: THE INNOVATIVE SOLUTION 6
IV. PROJECT METHODOLOGY: THE PROCESS 7
V. PROJECT ACCOMPLISHMENTS: THE OUTCOMES 8
VI. PROJECT SUMMARY: THE BENEFITS 9
VII. APPENDIX A: SERVICE INTEGRATION PROJECT AWARDS 11
1. Board of Supervisors Scroll
2. Board of Supervisors Certificate of Recognition
3. National Association of Counties Achievement Award
VIII. APPENDIX B: INTEGRATION PLANNING GUIDELINES (UNEDITED) 14

Developing an Innovative Service Integration Model In Los Angeles County : SPA 3 4 Case Study July 2005
34
EXECUTIVE SUMMARY
i. EXECUTIVE SUMMARY
Integration efforts of the health
system in Los Angeles have rarely
worked and even failed due to differ-
ing definitions of integration and“co-
location, expansion and take-over”
initiatives resulting in health care
organizations and providers working
independently and/or duplicating
efforts. Over the past few decades,
counties, health experts and health
care providers have used the word
“integration”with a variety of mean-
ings and in different situations. To
some, integration may mean a new
organizational structure merging
various disease control programs
or services. For others, integration
means regular coordination through
information dissemination and
exchange among decision mak-
ers and program managers. Others
view integration as the sharing of
resources such as transportation
among different providers, expand-
ing services or co-locating different
institutions in the same building,
or adding tasks to already overbur-
dened staff. However, integration is
not just service provider networking,
community development, facility
co-location, expansion or take-over,
direct service gap filling, increasing
access to services, pleasant part-
nerships, or a great vision and few
concrete activities. All of these views
fail to appreciate that the aim of
integrating services is to enable the
overall health system to provide the
right care in the right place to more
people in terms of both quantity and
quality.
Therefore, the Metropolitan Service
Planning Area Health Office (SPA 4)
transformed a“Co-Location Project”
between the Los Angeles County
Department of Health Services (DHS)
and The Los Angeles Free Clinic
(LAFC) into a Service Integration
Project (SIP). This was accomplished
at the Hollywood/Wilshire Health
Center (HWHC) by promoting a
shared-vision and four Fundamental
Integration Principles (Sharing of
Responsibilities, Enhanced Coverage
and Quality, Customer Focused Ser-
vice, Optimization of Resources), and
organizing and deploying 5 Integra-
tion Planning Teams (Clinical Services,
Business Office and Facility Manage-
ment, Human Resources, Information
Technology, Marketing and Develop-
ment). This enabled DHS to provide
appropriate services to more people,
closer to where they live and work, at
an earlier stage of disease develop-
ment, and as part of a continuum of
care process. As a result: (1) HWHC
has seen a 70% increase in patient
load, (2) patients have increased
access to primary health care and
public health services, (3) a Model
Center of Community Health and
Social Services is being created, and
(4) status quo is being replaced by
value added public health initiatives
that are moving public health into
the 21st Century.
The First Anniversary Celebration of
the HWHC Service Integration Project
was held on April 4, 2003. The event
was placed into the larger context
of what was achieved by the SPA 4
Area Health Office by commemorat-
ing more than just, and beyond what
was, a successful partnership be-
tween the DHS and LAFC. The event
celebrated the restructuring of the
way business was traditionally done,
the strengthening and promotion of
excellence in service delivery, and the
delivery of enhanced services to the
community.
Phase I of the Service Integration
Project included the integration
of Primary Care and Public Health
Services. Phase II of the project was
implemented three years later by
adding select Specialty Care and
Social Services in 2005. The safety
net to Hollywood’s underserved
populations was expanded through
DHS focus on the Service Integration
Model developed by the SPA 4 Area
Health Office. In April 2003, the Los
Angeles County Board of Supervisors
awarded a Scroll for the Revitalization
of the Hollywood/Wilshire Health
Center with the renovation of the
facility and restoration of primary
care medical services through and
integrated service model. In Octo-
ber 2003, The Board of Supervisors
awarded Certificate of Recognition
to the Service Integration Project for
“Enriching Lives, Quality and Pro-
ductivity”and Los Angeles County
received the 2004 Achievement
Award of the National Association of
Counties in recognition for an innova-
tive program which contributes to
and enhances county government in
the United States (Appendix A).
INTEGRATION PRINCIPLES
1. Shared Responsibilities
2. Enhanced Coverage and
Quality
3. Customer-Centered
Services
4. Optimization of Resources

PROJECT BACKGROUND
5
I. PROJECT BACKGROUND: THE
OVERVIEW
In 1997, following unprecedented
service cuts in the county system
that left tens of thousands of people
without access to primary care, the
Los Angeles County Department of
Health Services sought to partner
with community clinics in an effort
to continue services for its patients.
Years of shrinking public dollars
and an ongoing State and County
budget crisis over the previous
decade changed the way all agencies
delivered health care in Los Angeles.
In order to bridge the gap, continue
to serve county residents and, more
importantly, develop an integrated
health services system, strategic
alliances and partnerships were
created with non-profit community
clinics. During this time, there was
much discontentment and frustra-
tion from DHS patients, customers
and the community due to a frag-
mented patchwork of health and
human services. It was very difficult
for the people to navigate through
the health care system and obtain the
health care services that they needed.
DHS attempt to develop an inte-
grated health services system with
the private sector was based on three
fundamental strategies:
(1)“Co-Location Projects”where a
public and a private health provider
utilized the same facility to service
clients retaining each ownership of
clients and autonomy of operations,
(2)“Expansion Projects”that increased
the size, volume, quantity or scope of
services provided by an existing DHS
health center, and
(3)“Take-Over Projects”where private
providers assumed total control,
management and/or responsibility of
DHS facilities.
The Los Angeles Free Clinic was one
of the clinics selected to enter into
the Public/Private Partnership Pro-
gram by the Third District of the Los
Angeles County Board of Supervisors
(BOS). A co-location project between
LAFC and the Hollywood/Wilshire
Health Center was envisioned and
multiple site visits were made by
LAFC, BOS and DHS staff to plan for
the project and discuss the most
appropriate areas to co-locate LAFC
services. In August 1999, the newly
appointed Area Health Officer for the
Metropolitan Service Planning Area
(SPA 4) was charged with the respon-
sibility to bring this project to fruition.
DEFININGTHE PROBLEM:
MACRO LEVEL
•Government has a duty to
assure the public’s health
•Government cannot do it
alone,other sectors have a
role to play
• Need for inter-sectoral
engagement
DEFININGTHE PROBLEM:
MICRO LEVEL
10 million people
236,000 homeless
53% low literacy rate
31% no medical insurance
35% no dental insurance
DHS budget constraints:
Reduction in force and closure of
clinics,emergency departments,
hospital services and trauma
centers
Figure 1. Assuring the population’s health

PROBLEM STATEMENT PROJECT APPROACH
56
II. PROBLEM STATEMENT: THE
CHALLENGE
The effects of barriers to health care
access were felt in the late 1990’s and
early 2000’s throughout Los Angeles
County (LAC), but nowhere were they
more noticeable than in SPA 4. Resi-
dents of Metropolitan Los Angeles
represented 24.75% of all cases of
advanced HIV/AIDS in the county,
10.7% of cases of Hepatitis C, 24.3%
of cases of Tuberculosis, and 13.6%
of cases diagnosed with a Sexually
Transmitted Disease (STD). As the
unemployment rate grew the rate of
homelessness and under/uninsured
people grew also. Approximately
48% of SPA 4 residents had no health
insurance and over 8% reported be-
ing homeless at least once within the
last 5 years. Additionally, an estimated
44% of the population of SPA 4 lived
at the 200% Federal Poverty Level
($36,800 per year for a family of four).
For most families, it was difficult to
access health care because services
were scattered throughout a large
area, scheduling of appointments was
difficult, and there was limited quality,
culturally sensitive health care. Clo-
sures of health centers and services
and a DHS budget shortfall close to
one billion dollars aggravated this
situation. Consequently, one of the
DHS strategies to improve the per-
formance of the health system and
fill the gaps in services in SPA 4 was
the implementation of a Co-Location
Project between LAFC and HWHC.
The above described situation was
further compounded by the fact that
HWHC staff had not been officially
briefed, consulted or informed about
the co-location project with LAFC.
This resulted in mixed feelings among
staff ranging from fear of job loss,
displacement, uncertainty, confu-
sion, frustration, disappointment, lack
of appreciation for their work and
contributions, and lack of value for
public health services, to reluctance
and rejection to partner with LAFC.
Unfortately, this was indirectly and
involuntarily created by two years of
site visits that left messages regarding
what LAFC“wanted and was going
to be granted”rather than what LAFC
was contributing to or bringing to
HWHC and the health district.
III. PROJECT APPROACH: THE
INNOVATIVE SOLUTION
The SPA 4 Area Health Office was
assigned the responsibility to support
the DHS co-location of LAFC at the
Hollywood-Wilshire Health Center,
including support to the renovation
of the facility. In light of low morale is-
sues already described, in addition to
noticeable integration gaps between
DHS Personal and Public Health
Services as well as between DHS and
private providers, SPA 4 conceptual-
ized a Service Integration Project to:
(1) bring LAFC and HWHC staff
together on a common vision and
mission,
(2) advocate for“integration”instead
of“co-location”,
(3) develop project ownership among
LAFC and HWHC staff,
(4) motivate and boost the morale of
public health staff,
(5) educate about and raise the
importance of the core functions of
public health,
(6) better serve community residents
and patients, and
(7) challenge LAFC/HWHC staff to
develop a unique integration model
worthy of replication in other local,
state and national settings. Service
Integration Planning Guidelines (Ap-
pendix 2) were developed in January
2000 and presented to two subse-
quent LAFC Chief Executive Officers
and their Management Teams who
bought into the vision and con-
tributed thereafter to promote the
integrated health services approach.
In turn, SPA 4 transformed the DHS
co-location strategy into a feasible
Service Integration Model by devel-
oping and promoting the following
integration rationale:
• PROJECT PURPOSE: Create a
Model Center of Community Health
and Social Services which will be key
to promoting and building stronger
and healthier families and communi-
ties.
• PROJECT GOAL: Integrate four
project components –primary care,
specialty care, public health programs
and services, and social and commu-
nity services—through the collab-
orative efforts and complementary
capabilities and resources of the two
partnering institutions.
Integration is not...
• Service provider networking
• Community development
• Direct service gap filling
• Increasing health care access
• Pleasant partnerships
• A great vision with few
concrete activities
• New organizational
structure
• Regular coordination
through information sharing
• Sharing resources
• Co-location of different
institutions within the same
building

PROJECT METHODOLGY
7
FUNDAMENTAL INTEGRATION
PRINCIPLES:
o Sharing of Responsibilities, in-
cluding vision, governance, physical
infrastructure, and complementary
services for client, program and com-
munity betterment outcomes.
o Enhanced Coverage and Quality,
meaning better services at the point
of first encounter, closer to those
in need and where people live and
work, provided by a combination of
providers, and constituting the first
element of a continuing health care
process.
o Customer Centered Services, that
is, language and culturally sensitive
services for individuals, families and
the community with a common in-
take/reception and seamless service
delivery.
o Optimization of Resources, in
other words, to capitalize on and
maximize the use of LAFC and DHS
capabilities in a complementary fash-
ion avoiding duplication of efforts
and services.
IV. PROJECT METHODOLOGY:
THE PROCESS
The renovation of HWHC to accom-
modate LAFC and reorganize public
health services was completed in
March 2002. The Service Integration
Project was seriously challenged by
multiple renovation and staff issues
connected to cumbersome contract-
ing, monitoring and oversight issues
expected in a bureacratic setting
lacking renovation performance ac-
countability and sanctioning. Never-
theless, the vision and determination
of the LAFC/HWHC Leadership Team
maintained the project on course
by addressing emergent construc-
tion and personnel issues and, most
importantly, encouraging and ral-
lying staff consistently towards the
creation of a Model Center of Com-
munity Health and Social Services.
While both partners shared similar
values and ideals, a long list of chal-
lenges to integrated health services
emerged. The crucial question was
“how would it be possible to inte-
grate two different businesses with
different policies, procedures and
practices and yet provide seamless,
comprehensive services for patients”?
As with any integration project, there
are possible risks including a shared
liability, conflict in management
styles, resentment, and funding dis-
parities for the institutions. In order
to address these and other issues, five
Service Integration Planning Teams
were created. Each team consisted
of experts in particular subject areas
that reported regularly to the SIP
Integration Leadership Team that
monitored process ensuring account-
ability as follows:
1. Clinical Services Integration Plan-
ning Team: This team addressed the
issues related to the type of services
that would be provided by each
partner keeping in mind the goal of
providing seamless, comprehensive
care to patients without duplication
of efforts. Other issues tackled by
this team included how to deal with
walk-in patients as well as the patient
referral process within the center.
2. Business Office and Facility
Management Integration Planning
Team: This team addressed building
concerns such as janitorial and secu-
rity services and designed the shared
registration area to present a seam-
less appearance to patients. Although
an integrated medical record was the
ideal, existing HIPAA (Health Insur-
ance Portability and Accountability
Act), County and State regulations
prohibited it. This team explored al-
ternative options on how the medical
records systems should be handled.
Other issues addressed by the team
included assignment of work spaces
and parking spaces.
3. Human Resources Integration
Planning Team: Issues discussed
by this team included opportuni-
ties to share employee training and
incorporating volunteers into service
provision. This team was also tasked
with developing recommendations
on how to respond to employees’
reactions, how to inform them of the
process, how to anticipate and deal
with Union issues, and how to keep
the workforce motivated.
PURPOSE OF
INTEGRATION
To enable the overall health
system:
• to provide appropriate
services to more people
• closer to where they live
and work
• at an earlier stage of
disease development,
• at the point of first
encounter
• by a combination of
providers
• constituting the first
element of a continuing
health care process.
SPA 3 4 Area Health Office

4. Information Technology Inte-
gration Planning Team: This team
addressed issues related to integrat-
ing two separate information systems
including the selection of the most
appropriate telephone system for the
center.
5. Marketing and Development
Integration Planning Team: Issues
addressed by this team included
advertising and marketing strategies,
particularly how to introduce the new
center to the community. Coordina-
tion of health information, educa-
tion, communication and outreach
services were also discussed by this
team.
The five Integration Planning Teams
were organized and deployed in No-
vember 2001 to review and implement
integration guidelines in their respec-
tive areas. Teams met extensively
during a 3-month period (January
– March 2002) and reported monthly
to the SIP Integration Leadership Team
consisting of LAFC and SPA 4 Senior
Leaders. The official start date of the
Service Integration Project was April 1,
2002. Since then, monthly meetings
continue to assess progress to date,
further define the meaning and extent
of integration, and make changes and
adjustments as needed.
V. PROJECT ACCOMPLISH-
MENTS: THE OUTCOMES AND
LESSONS LEARNED
The LAFC and SPA 4 Area Health Office
shared the values of providing high
quality, non-judgmental, patient–cen-
tered care. Together through this part-
nership, the delivery of broader, more
comprehensive services at an earlier
stage of disease development, to more
people and closer to those in need by
the combination of two providers was
possible constituting the first element
of a continuum of health process. Con-
sequently, the SIP goal to better serve
patients and customer at their point of
first encounter was fulfilled.
Figure 2. Integration Teams
PROJECT ACCOMPLISHMENTS
8

PROJECT ACCOMPLISHMENTS PROJECT SUMMARY
9
Implicit in the idea of integration was
the customer-focused care principle.
Integration of programs and services
was viewed from and based upon the
patient’s perspective, i.e. an individual
seeks help and health care services at
HWHC where comprehensive –prima-
ry and specialty care combined with
public health and social services-- are
delivered independently of who
[which partner] provides the service.
From the patient’s perspective, he/
she can resolve his/her medical,
public health and/or social need at
HWHC, not at the Los Angeles Free
Clinic housed in the facility or at the
DHS clinics located in the health cen-
ter. Hence, HWHC is not a“co-location
of independent entities”but rather an
“integrated center of programs and
services”for individuals, families and
the community based on a true, col-
laborative partnership. The vision of
the center to provide patients a place
that could meet most of their health
and social needs was also fulfilled.
Also, this was strongly supported
by language and culturally sensitive
services, a common intake reception
area, and seamless service delivery.
was also viewed from an optimiza-
tion perspective; that is, aiming to
develop a partnership to the utmost
extent in order to obtain the most ef-
ficient use of DHS and LAFC capabili-
ties. Avoiding duplication of services
and eliminating wasteful spending
was essential. For example, instead
of having two STD and TB Clinics at
HWHC, what was working well was
kept in place and new services were
added to satisfy unmet needs and fill
the gaps in other services or special-
ties, i.e. primary care and selective
specialty care. This allowed both
partners to contribute to each other
with their particular strengths and
expertise.
What occurred between DHS and
LAFC is more than just, and beyond
what is, a successful partnership. It is
indeed a model Service Integration
Project that: (1) restructured the way
business was done in Los Angeles,
(2) strengthened and promoted
excellence in service delivery, and (3)
provided better services to commu-
nity residents.
The“revitalized”Hollywood-Wilshire
Health Center began to operate in
April 2002 as a Service Integration
Project, a joint venture between DHS
and LAFC. Initially, primary care was
integrated with public health servic-
es. Three years later, select specialty
care and social services were added.
By late summer of 2005, the ser-
vices that were offered at the center
included primary and specialty care;
treatment of STD and TB; immuniza-
tion services; refugee health services;
dental services; vision screening;
transportation; health promotion/risk
reduction prevention programs; basic
laboratory support; mental health
and case management; and public
health nursing services. In addition,
there was a dispensing pharmacy on
site and HWHC offered services to
infants, children, adolescents, adults
and the elderly.
This collaborative venture provided
stability, expanded access to health-
care, diversified services, delivered
high quality care and“one stop shop-
ping”for patients, and allowed better
utilization of resources. The HWHC
SIP inaugurated a bold experiment
that became a model of healthcare
delivery, cementing the relationship
between DHS and LAFC through a
mutually beneficial and cost-effec-
tive approach. Most importantly,
it marked a huge boost in service
for patients who are now able to
visit a single location to be seen by
a primary care physician and receive
public health services free of cost.
As a result of this Service Integra-
tion Project, HWHC has seen a 70%
increase in the patient load. Commu-
nity residents have increased access
to primary health, public health,
specialty care and social services. SIP
has made it easier for patients to ac-
cess services by providing them with
a single point of entry and allowing
them to receive in one facility a broad
range of assistance normally provid-
ed in different locations. In addition,
a Model Center of Community Health
and Social Services was created and,
more importantly, status quo was re-
placed by value-added public health
initiatives that are moving healthcare
into the 21st Century.
VI. PROJECT SUMMARY: THE
BENEFITS
The purpose of this publication was
to showcase the development and
implementation of an integrated
health services initiative as a concep-
tual model and framework for“trou-
ble-shooting and problem-solving”
of health issues, increasing access
to health care services, developing
leadership teams and workforces,
and enhancing the performance
of the Los Angeles County health
system as a whole. As such, there is
no discussion about budget implica-
tions, expenditures to renovate the
Hollywood/Wilshire Health Center
or funding given to LAFC under the
Public/Private Partnership Program.
At the time of this project, the total
DHS funding for this program is more
than $40,000.00 for over 30 commu-
nity clinics and a cost-effectiveness,
cost-utility or cost-benefit analysis is
beyond the scope of this publication.

10
The Service Integration Project pro-
vides services to community residents
in an atmosphere of cooperation, qual-
ity and accountability. The project al-
lowed residents to access high quality
essential primary care, specialty care
and public health and social services
in a single location without having
to drive across town. LAFC and SPA
4 patient loads increased by 70% in
2002 (from 36,000 to 62,000 clinic visits
per year). Additionally, public health
patients gained a“medical home”and
access to primary and specialty care
providers that were not easily avail-
able prior to the integration. Similarly,
primary care patients are able now to
access public health services without
having to leave the building.
PROJECT SUMMARY
Finally, we trust that this integration
approach will be useful to public,
private and non-profit medical and
public health departments, organiza-
tions, programs and providers as they
continue to improve the quality of
services, enhance the performance of
their systems and developed integrat-
ed health services models. The lessons
learned from this project have been
instrumental in the SPA 4 Area Health
Office for capacity building and leader-
ship development purposes, as well as
a motivation to develop an approach
to better integrate the DHS personal
and public health functions.
Figure 3. Service Integration Project Model

9
APPENDIX A: Board of Supervisors Scroll
11

12
APPENDIX A: Board of Supervisors Certificate of Recognition

13
APPENDIX A: National Association of Counties Achievement Award

14
APPENDIX B
INTEGRATION PLANNING
GUIDELINES (UNEDITED)
Health Office, DHS/PHPS
January 28, 2000
This concept paper reflects the
Metro SPA Area Health Office general
thinking to date to operationalize
service integration at the Holly-
wood/Wilshire Health Center. It is
not meant to be comprehensive at
this time, but rather a starting point
for discussion across organizational
lines. It will be subject to modifica-
tion and refinement as we continue
to learn how to integrate public
health, personal and private partner
health services. We hope this docu-
ment will be useful for developing
a Memorandum of Understanding
and/or Contract between the DHS
and the Los Angeles Free Clinic.
1. Project
Hollywood/Wilshire Health Center’s
Integration Project
2. Principal Partner Institutions
Los Angeles Free Clinic [LAFC]
Health Office, DHS/PHPS
3. Project Managers
Mary L. Rainwater, LCSW, Executive
Director, LAFC
M. Ricardo Calderón, MD, MPH, Area
Health Officer – Metro SPA

4. Strategic Intent
Shared [1] Vision
[2] Governance
[3] Physical Infrastructure
[4] Complementary Programs
and Services
5. Integration Rationale
5.1. Purpose
The purpose of the project is to cre-
ate/develop a model center of com-
munity health and social services,
which will be key to promoting and
building stronger and healthier fami-
lies and communities.
5.2. Goal
The project aims to integrate four
program components --primary care,
specialty care, public health pro-
grams and services, and community
services, through the collaborative
efforts and complementary capabili-
ties and resources of two partnering
institutions, the Los Angeles Free
Clinic and the Metropolitan Service
Planning Area Health Office of the
Department of Health Services.
5.3. Fundamental Principles
5.3.1.Customer focused/centered
services
is viewed from and based upon the
client’s or patient’s perspective, i.e., an
individual seeks help and health care
services at the
Hollywood/Wilshire Health Center
[HWHC] where comprehensive –
primary and specialty care combined
with public health and community
services - are delivered independent-
ly of who [which partner] provides
the service. From the patient’s per-
spective, he/she can resolve his/her
medical, public health and/or social
needs at HWHC, not at the LAFC ser-
vices housed in this center nor at the
DHS services located in it. Therefore,
the HWHC is not a“co-location of
independent entities”but rather an
“integrated center of programs and
services”for individuals, families and
the community based on a true, col-
laborative partnership.
5.3.2. Optimization of Resources
is also viewed from an optimiza-
tion perspective; that is, aiming to
develop a partnership to the utmost
extent in order to obtain the most
efficient use of DHS and LAFC capa-
bilities. Hence, a second integration
principle is to capitalize on and maxi-
mize the use of current HWHC and
LAFC resources in a complementary
fashion avoiding duplication of time
and efforts and wasting of resources.
For example, instead of having two
STD and TB Clinics at HWHC, what is
working well is kept in place and new
services are added to satisfy unmeet
needs and fill the gaps in other ser-
vices or specialties, i.e., primary care
and selective specialty care.
5.4. Scope of Work
HWHC’s“community health services”
is essential medical and public health
care based on practical, scientific
and socially acceptable methods and
technology. It will be made univer-
sally accessible to individuals and
families in the community through
their full participation at an afford-
able cost. HWCH’s integrated services
will be one of the central functions
and the main focus of the Hollywood/
Wilshire District Health System and
of the social and economic develop-
ment of the community. It will be a
first contact point for the individual,
the family and the community with
the Public/Private
Partnership Health System, bring-
ing health care as close as possible
to where people live and work, and
constituting the first element of a
continuing health care process. The
comprehensive community health
services will rest on the following
elements:
• Primary medical care for children
and adults, including reproductive
health services.
APPENDIX B: Integration Planning Guidelines (UNEDITED)

15
• Immunizations against the major
infectious diseases
• Appropriate treatment of common
diseases and injuries
• Categorical clinics for specialty
care needed by the commu
nity including referral services and
agreements with other health care
providers
• Health promotion, risk reduction
and disease prevention programs
including promotion of proper
nutrition and education on prevail-
ing health problems and methods
of prevention and control
• Provision of essential drugs and/or
prescriptions
• Public health investigations
• Basic laboratory support and refer-
ral services and agreements
• Community meeting and informa-
tion services including center-
based and outreach programs, i.e.,
social, educational and legal assis-
tance and prevention and
response programs for domestic
violence, child abuse, elder abuse
and sexual assault.
• Case Management referrals and
information.
• Flexibility to adapt programs and
services to meet changes in com-
munity needs and priorities
6. Description of Key Project Compo-
nents
6.1. Triage Services
Currently DHS/HW provides Com-
municable Disease Triage services
through Registered Nurses, 98%
tuberculosis screening and 2%
communicable disease treatment
respectively. The LAFC provides tri-
age and referral services to determine
same day walk in appointments, and
information regarding accessing
LAFC appointments by phone, as well
as community referrals.
With the integration of DHS and LAFC
services at HWHC, Triage Services
must be enhanced to provide internal
and external referrals that meet the
specific needs of those requesting
medical service consultation and
intervention. Historically, all services
offered in County Public Health Cen-
ters begin with the Registration Win-
dow as the entrant’s first“stop”. After
the person is financially screened,
she/he is then referred to a specific
categorical clinic or to Triage.
We propose a new system, not unlike
that used in Emergency and Urgent
Care Centers, where the entrant,
unless pre-appointed to a clinic, is
directed to a triage office, seen by a
staff (DHS/LAFC staff composition
to be determined), and screened for
the type of problem. From the triage
area, the staff will determine what
type of initial evaluation, clinical or
social service is needed for the client
–immunizations, tuberculosis, STDs,
refugee’s health services, primary and
specialty services, financial screening
for insurance and financial assistance,
dental, vision, nutrition, smoking
cessation, transportation, language,
child care, etc.-- and, when on-site
service is indicated, direct the client
appropriately. Triage Services would
facilitate access to services directly
through interacting with the appro-
priate staff and making the patient’s
various stops through the system as
simple and seamless as possible, in-
cluding referring and/or assisting the
client in attaining service off-site.
6.2. Management of Tuberculosis
Trained and certified physicians staff
the TB Clinic at HWHC. This clinic
also has associated infrastructure
to provide the patient an array of
services to facilitate adherence with
prescribed medication. These ser-
vices include culturally and linguisti-
cally compatible outreach and clinic
personnel to provide transportation,
directly observed therapy and inter-
pretation. In addition, incentives are
often provided to raise the priority
of appropriate care for their disease.
Housing is provided for the homeless
and food for the hungry, as well as
clothing and other essential needs in
exchange for adherence to treatment
regimens. Bus passes and tokens are
also utilized to overcome transpor-
tation barriers when necessary or
effective. These services are accessed
through the current HWHC’s TB
clinic and its methodology has been
effective in the identification and
resolution of barriers to completion
of therapy for TB disease.
In Los Angeles County, directly
observed therapy is the“standard of
care”for all TB cases and suspects.
Few, if any, private providers or
community-based primary care clin-
ics have the infrastructure to support
these extensive outreach efforts. The
DHS public health clinics also have
Public Health Investigators whose
role it is to follow-up on recalcitrant
and non-adherent patients to return
them to treatment. If all else fails,
DHS has the authority to legally
detain patients that, despite our best
efforts, continue to place the public
at risk for transmission. Public Health
Nursing is involved with the family
and other close contacts to these
patients to provide screening, evalua-
tion and education. The entire range
of services is available to the patient
population under the umbrella of the
DHS TB clinic. There are no efficien-
cies to be realized by fragmenting
these services. Having patients clini-
cally managed by LAFC and provided
support (case management) services
by public health is unnecessarily
complicated with no advantages to
the patient population.

916
The integration of a TB public health
clinic and a private non-profit pri-
mary care clinic can provide benefits
to patients that neither entity can
provide alone. TB patients often
suffer from other conditions and the
ability to refer a TB patient for care of
these conditions to a co-located pri-
mary care clinic would be a substan-
tial improvement over referral to a
County hospital. Likewise, the ability
of a primary care clinic to refer a
patient with TB-like symptoms identi-
fied through screening to an on-site
public health clinic specializing in TB
management would be an improve-
ment over an off-site referral.
Therefore, the public health TB clinic
will:
• remain responsible for patient
medical and case management
[clinical services for the screen-
ing, diagnosis and treatment of
tuberculosis including prophylaxis/
preventive therapy and field services
of observed medication therapy,
monitoring of treatment compliance
and contact tracing],
• serve as a referral source for all tu-
berculin skin test reactors for whom
active disease needs to be ruled out,
• assist and consult with the LAFC
staff as requested, along with as-
sistance from the DHS TB Control
Program when medically indicated
for the evaluation of tuberculosis, and
• monitor the treatment of tuber-
culosis in patients with concomitant
illnesses managed by LAFC.
The LA Free Clinic will:
• refer TB patients and/or manage
them in conjunction with the HWHC
TB clinic,
• serve as a referral source for
patients with other acute or chronic
conditions,
• provide primary care for tuberculo-
sis patients as indicated and avail-
able and care for diabetes and other
chronic conditions, as appropriate.
The DHS and LAFC staff will work
jointly to coordinate care for the
patient through both informal con-
sultations and potentially, formal case
conferences, and both entities will
continue to follow mandated report-
ing requirements. However, when a
high risk situation arises or is made
apparent, LAFC and DHS will refer to
each other for immediate interven-
tion, i.e., LAFC evaluates someone
who they suspect has active TB or
DHS sees someone with grossly
elevated blood glucose.
6.3. Management of Refugee’s Health
(Note: this whole area needs addi-
tional collaboration)
The Refugee Health Clinic may
provide the best opportunity for not
only cooperative co-location, but also
true collaboration and integration be-
tween DHS and LAFC. While screen-
ing services have been provided to
the refugee population by culturally
sensitive and linguistically competent
teams at both Hollywood and Central
Health Centers, the DHS current
level of staffing cannot accomplish
the new requirement for a complete
history and physical. In order to ac-
complish what is now required, the
TB Control Program contracts with
H. Claude Hudson Comprehensive
Health Center and the Los Ange-
les County-University of Southern
California Medical Center to utilize a
Nurse Practitioner currently providing
primary care services at HWHC. It is
not anticipated that this arrangement
will be practical in the future as LAFC
will replace the services currently
provided by Hudson.
The TB Control Program has a Nurse
Practitioner position funded by the
State to provide expanded screening
services to the refugee population.
DHS physicians are very specialized
and aren’t comfortable acting as
preceptor for the Nurse Practitioner.
LAFC physicians practice general
medicine and could provide the
oversight needed to accomplish the
expanded screening utilizing a Nurse
Practitioner. The compensation for
preceptor services could be negoti-
ated at a later date. It would also be
possible to fund a Nurse Practitioner
position for LAFC, if such an arrange-
ment offers advantages to LAFC. Any
time not utilized in the evaluation of
refugees would be available to serve
in LAFC clinics. There may be other
variations that could be even more
advantageous and the TB Control
Program is open to further discus-
sions in this matter.
The Refugee Clinic at HWHC evalu-
ates approximately 100 refugees per
month, while the clinic at the Central
Health Center sees 125. Many health
problems, minor and severe, requir-
ing various levels of referral and
medical management appear in this
population. Referrals are currently
made to hospital-based clinics for fol-
low-up, as no comprehensive primary
care services are available in either
of these two public health centers.
Referrals could be made just as easily
to the LAFC with refugee health team
members providing the necessary
interpretive and support services.
This may be more convenient for the
patient population and would at the
very least provide a referral option for
these patients. Refugees are eligible
for Medi-Cal thirty days after their
arrival. This could provide a rev-
enue stream for LAFC with minimal
investment in eligibility screening
as sponsors have often cleared this

17
hurdle prior to medical evaluation in
the refugee clinic.
6.4. Management of Sexually Transmit-
ted Diseases [STDs]
The Hollywood/Wilshire District is a
unique area since it has a considerable
number of street youth; it is a portal
of entry for immigrants primarily from
the former Soviet Union where both
TB and Syphilis incidence is high and it
has STD rates near those of LA County
“core districts, i.e., highest number of
reported congenital syphilis among LA
County’s 23 Health Districts, and top
rank in reported chlamydia and gonor-
rhea cases.
The collaborative partnership between
DHS and LAFC can strengthen and
expand STD/HIV prevention services,
maintain and expand partner services,
maintain the DHS categorical STD
clinic as a center of excellence, and
create collaborative opportunities to
develop top-quality services such as
potential joint case conferences, STD
program-credentialed clinical staff,
participation in STD Control Program
in-service education programs [3rd
Friday of each month] and joint quality
assurance activities.
Therefore, the proposed operation and
management of STDs at HWCH will
comprise the following:
• Offer choices to clients/patients to
the maximum extent possible
• Direct callers or walk-ins primarily
to the DHS STD clinic
• Use compatible intake, interview
and exam processes, as possible
• Use non-intrusive testing [first-
voided urine, oral mucosal transu
date, etc.]
• Provide joint access to on-site facil-
ity laboratory services, as possible
• Initiate partner services at initial
visit
• Offer HIV counseling and testing
• Provide CDC-recommended single-
dose oral treatments
• Comply fully with Confidential
Morbidity Reporting
• Encourage enrollment in LAFC as a
“medical home”
• Offer immunizations, information
and/or referrals, i.e., Hepatitis A B
• Provide referrals to alcohol/drug
treatment and mental health ser-
vices
• Provide transportation assistance if
necessary, i.e., bus tokens
• Share written resources, i.e., treat-
ment guidelines, case definitions,
manuals, Public Health Newsletter,
STD Examiner, etc.
Both DHS and LAFC will continue to di-
agnose and treat sexually transmitted
diseases as they currently are including
mandated reporting requirements.
The difference is that public health will
do immediate contact interviewing
and has the capacity for rapid HIV test-
ing. On triaging, DHS will be the pri-
mary referral for a single STD episode.
Patients will access care through LAFC
if other problems exist or they are ex-
isting LAFC patients. When a high-risk
situation exists or is made apparent,
DHS and LAFC will refer to and consult
with each other for immediate inter-
vention, i.e., when immediate contact
interviewing is important, LAFC has a
client with +STD, possible incidents of
child abuse, etc.
6.5. Management of Immunization Ser-
vices (Note: this whole area needs to
be revisited given the funding planned
for the site/visits)
Currently both DHS/HWHC and LAFC
provide immunization services. Both
are non-profit providers receiving their
vaccine from the DHS Immunization
Program. Both adhere to the Immuni-
zation Program guidelines for age of
administration, reporting procedures
and annual audits. The difference is
that LAFC also provides adult immu-
nizations by purchasing vaccine. To
consolidate services and simplify ac-
cess for patients, we propose that LAFC
provide all immunization services in
the Hollywood/Wilshire Health Center.
The exception will be the DHS annual
Flu Program and periodic outreach
clinics.
6.6. Laboratory Services
Currently, the HWHC does not have a
laboratory onsite. Testing to rule out
communicable diseases is sent to the
DHS Central Laboratory and any other
tests, such as complete blood counts,
blood glucose and chemistries are
done at the LAC+USC
Medical Center Laboratory. The DHS
Public Health and the Personal Health
clinics utilize both laboratories.
Per physician orders, nursing is
responsible for the collection of all
lab specimens. Specimen collection
includes blood, urine and sputum, as
well as throat, lesion and rectal swabs.
On occasion, specimens from animals
suspect in communicable disease
investigation are also collected. After
collection, specimens are labeled
and packaged for safe transport, and
placed in the HWHC Business Office
for pickup by couriers from each lab
site. Couriers pick up tests daily. The
processing time for both laboratories is
between three to seven days including
a procedure for“critical value”result
notification by both labs. Critical value

18
notification for LAC+USC Laboratory is
conducted by the LAC+USC Customer
Care Center for both Personal and
Public Health clinics. Public Health con-
ducts its own notification for critical
values.
A small on-site laboratory capability
is proposed by LAFC as follows for
rapid turnaround of simple diagnostic
tests for common ambulatory medical
conditions, thus minimizing referrals to
an outside laboratory:
• pregnancy tests
• urine dip and microscopic
• finger stick glucose and hemoglo-
bin
• rapid strep
• wet mounts/KOH preps
• cholesterol/cbc/simple blood
chemistry
• phlebotomy to send out blood
specimens
• preparation of samples to send
out for microbiological exami-
nation, pathology, (i.e., paps, stool
culture), etc.
• Injection and TB testing would be
conducted by either nursing or
laboratory personnel
The LAFC would be responsible for the
above laboratory services at the HWHC
and provide lab technician coverage
for any clinic session.
6.7. Dispensary/Pharmacy Services
There are no on-site pharmacies in any
Public Health facilities and, therefore,
pharmacy services are primarily con-
ducted by health center nursing staff.
The Community Health Services [CHS]
and LAC+USC pharmacy follow the
CHS Pharmacy Policy and Procedure
Manual with regard to the use of medi-
cations in the Public Health Centers.
This Manual also provides a formulary
of medications that are stocked or
that can be special-ordered from the
Pharmacy at LAC+USC. Prescriptions
for outside pharmacies are usually only
written for communicable disease con-
trol situations in institutional settings.
Additionally, the Auditor Controller
mandates a system of monitoring high
cost/high volume medication that is
maintained under a special drug moni-
toring procedure.
The HWHC Clinic Nursing Staff, under
the direction of a Supervisor Clinic
Nurse 1, is responsible for stocking
(medications are stored in each clinic
area in locked cabinets), -ordering, as-
suring the integrity of the medication,
administering (medications are given
during clinic visits, on a walk-in basis,
delivered for the purpose of directly
observed therapy), maintenance of
medication supplies (bi-monthly
inventory for the purpose of order-
ing), and inventory of high cost/high
volume medications after each session
in STD and TB Clinics. The LAC+USC
Pharmacy is responsible for supplies,
consultation, special orders, monthly
inventory to ensure all drug dispens-
ing meets regulated and professional
standards, and bi-monthly delivery.
Since in–house dispensary services are
essential to facilitating patient’s access
to medications, the LAFC will support
patients’needs as follows:
• Provide patient education, drug
information and interaction assess-
ment through a pharmacist and/or
dispensing RN.
• Provide and stock basic generic
medications for common ambu-
latory conditions, including family
planning methods, bandages,
splints, injectables, medication
samples, etc.
• Medications not available in the
dispensary will be available for PPP
patients to have filled by an outside
contracted pharmacy at no cost to
patient.
• Patients with Medi-Cal or other
health coverage, or receiving
services reimbursable by FPACT,
may also receive medications at out-
side pharmacies with billing
handled by those respective agen-
cies.

Metropolitan Service Planning Area (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
Tel: (213) 240-8049
Fax: (213) 202-6096
www.lapublichealth.org
© 2005 SPA 3 4

Developing an innovative service integration model in Los Angeles

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