On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 2 | Pag e AltaMed Health Services: On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care
INTRODUCTION
Background
Founded in 1969, AltaMed is a non-profit 501(c)(3) Federally Qualified Health Center (FQHC). Now the largest FQHC in California, AltaMed’s regional health network offers a medical home in LA and Orange County (OC) with a full range of primary care, enabling and social service programs to low-income underserved communities for over 270,000 predominantly Latino children, youths, adults and seniors, 14% of which are uninsured. Target patients are by definition vulnerable, underserved populations and AltaMed is committed to provide quality care without exception to all patients, regardless of their ability to pay. With 98% of our total patient population living at or below 200% of the Federal Poverty Guidelines and 83% of our population identifying as Latino, the communities AltaMed serves have a higher likelihood to be without insurance or have insufficient coverage; reside in an area with a shortage of primary care providers; have language or other cultural barriers that prevent them from accessing care or from navigating the health care system; or have illnesses or conditions that have expanded their needs beyond their coverage. This community has significant disparities in health care access, quality and outcomes. AltaMed’s proposed Primary Care Clinic pilot will be deployed in the City of Vernon, in close proximity to several of AltaMed’s primary care clinics in Los Angeles County, communities with significant disparities in income and access, and with significant numbers of unsheltered populations. The proposed portable clinical care pilot will target unsheltered populations and surrounding community members in Los Angeles County.
Homelessness and health are inextricably linked. People experiencing homelessness often have serious physical and behavioral health needs but little access to traditional health care facilities and providers.
AltaMed seeks to provide access to high quality, culturally connected care to approximately 4,000 individuals in Vernon and the community who may be unsheltered, commuter, working residents and constituents through its Portable Clinical Care model. AltaMed understands the critical importance of implementing a Portable Care Clinic model that 1) understands the linguistic and cultural needs of a growing Latino demographic amongst the unhoused population; 2) connects the population served with necessary healthcare services that more comprehensively address their needs, from primary care to mental health; and 3) meets community where they are.
According to data from the Los Angeles Homeless Services Authority, which is the lead agency for the Los Angeles HUD Continuum of Care (HUD CoC; Los Angeles City & County CoC CA-600), there were more than 75,000 individuals experiencing homelessness in LA County in 2023. This represents an increase of more than 9% from 2022 and more than 43% since 2018. Unsheltered homeless populations increase 14% from 2022 up to more than 55,000 individuals. AltaMed’s community clinics are primarily in LA Service Planning Areas 2, 4, 6, and 7 and these areas had the highest amounts of unsheltered individuals in 2023, with SPA 2 (10,443), SPA 4 (18,531), SPA 6 (12,995), and SPA 7 (6,511 individuals). In addition, more than 25% reported serious mental illness in 2023. There is also an increase (nearly 50%) of transition age youth (aged 18-21 years old) who are experiencing unsheltered homelessness in 2023. Further data shows that 30% of unhoused individuals experience a substance use disorder in 2023, an increase from 26% reported from 2022. While the state average overdose death rate may not rank high in the nation, the communities AltaMed serves have a disproportionately high incidence, with several communities 25%- 70% higher than the state average of 4.79 per 100,000. Within AltaMed’s Los Angeles County services On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 3 | Pag e area, zip codes and their corresponding communities with overdose death rates greater than the state rate include Boyle Heights (8.08 per 100,000), Downtown LA (6.97 per 100,000) and Montebello (5.43 per 100,000).
Program Description
The City of Vernon and AltaMed share a mutual commitment in ensuring the health, safety, and wellbeing of its residents, workers, visitors, and neighboring communities. For over 55 years, AltaMed has worked to provide access to point of care services for high need individuals and connecting them back to shorter and longer term care so that their health outcomes may improve. For over 20 years, AltaMed has managed and executed mobile health unit programs, providing in-place services, that are both culturally and linguistically competent, to our shared communities. AltaMed seeks to expand this work in partnership with the City of Vernon, utilizing its “Health Bungalows” and mobile units to conduct a hub-and-spoke care model for its community.
AltaMed’s proposed program will deploy a phased clinical care service pilot to unsheltered individuals in City of Vernon and surrounding neighborhoods with a specific target of integrating Behavioral Health (including substance use disorder), HIV testing and treatment, and social services support into the comprehensive care model that participants will benefit from. AltaMed will work in coordination with City of Vernon, its clinic sites located in Los Angeles County and social services partners to address the overall lack of health care infrastructure available to individuals experiencing homelessness in the region by implementing a multidisciplinary team coordination model that comprehensively addresses the needs of these populations.
Recognizing the intersectionality of social determinants of health with ethnicity, culture, and the impacts of systemic racism, it is clear that in order to address health disparities, particularly those impacting the underserved/unhoused Los Angeles community, AltaMed will target the following care gaps with its PCC model:
1) Access to primary care services: Many patients do not have access to clinical care services and do not know how to access care, apply for health insurance, or consistently access the health system and instead end up in the emergency room once health conditions escalate. AltaMed will provide primary health care services and supplies through the Vernon “Health Bungalows” and in-place via community outreach efforts and mobile unit events.
2) Behavioral Health and Substance Use Screening: AltaMed will integrate its behavioral health model and substance use/Medication Assisted Treatment (MAT) care into its PCC care model, deploying screenings such as Alcohol Use Disorders Identification Test (AUDIT-C and AUDIT) and substance abuse misuse using the Drug Abuse Screening Test (DAST-10). Once enrolled as an AltaMed member, patients will have access to AltaMed integrated Behavioral Health services, including therapy with licensed social workers for mild to moderate anxiety or depression, Medication Assisted Treatment, and referrals to specialty mental health services with AltaMed’s community partners.
3) Patient Education & Community Outreach: AltaMed will deploy teams to meet communities and where unsheltered populations congregate, in order to engage with patients, provide health education, and connect them to short and long term clinical and social services.
On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 4 | Pag e 4) Community Support Linkages: Unsheltered patients are medically and socially vulnerable and physicians are often unaware of how to manage their care and what services are available. AltaMed is working closely with LAHSA as they develop coordinated approaches to improve housing placement services and reduce the barriers to placing individuals in stable housing. However, many people do not know how to get connected with these agencies and how best to use their services.
AltaMed’s PCC will work to build awareness with both community members and its clinical teams, and to connect appropriate services and benefits to individuals.
The City of Vernon’s health hubs and mobile health units will be the initial step to link a prospective patient to their new medical home. AltaMed will employ a 3-phased approach to care, beginning with offering primary care services from the “health bungalows”.
Phase 1 Over the course of Year 1 (July 2024- July 2025), AltaMed will operationalize primary care services within one City of Vernon’s Health Bungalow. Basic primary care services will include: routine health check-ups and physical exams, diagnosis and treatment of acute and chronic illnesses (i.e. diabetes, high blood pressure, and hypertension), preventive services: immunizations, screening for HIV, TB, and Hepatitis, Health Education, Mental Health screenings and substance use disorder screenings, Case Management: referral to social services and housing resources, and Health Education. During this time, AltaMed will also buildout the necessary Health Information systems (E.H.R, practice management, data security) and business and clinical protocols and procedures necessary.
Phase 2 (November 2024): In Phase 2, AltaMed will expand Phase 1 services by activating two mobile units. AltaMed will administer community outreach, outpatient care, routine health services, and referrals to social services providers (housing, food resources, etc.). AltaMed will utilize the City of Vernon’s community outreach mobile unit to conduct community outreach and health education to local businesses and community members, promoting the services offered by The City of Vernon and AltaMed. Leveraging its community health status as a trusted messenger in the community, AltaMed will foster relationships with community members and begin to conduct in-place treatment and internal referrals via the City of Vernon’s mobile health unit. AltaMed’s PCC Team (a licensed vocational nurse, community health worker and case manager) will offer screenings and treatment through Vernon’s mobile health unit, such as: vital signs check, assess for critical health conditions, wound care, medication support, direct telehealth services (if needed) to address health care needs, trauma, behavioral health, and social service needs.
Phase 3 (January 2025): Phase 3 will serve to meet demand for complex health care needs by activating AltaMed’s referral system to specialty services and larger referral network. This work involves connecting patients with a case manager and social worker. The social worker will deliver therapy for mild-to-moderate cases of anxiety and depression. The case manager will coordinate clinical appointments and social service needs (food, housing) throughout the scope of this partnership. AltaMed recognizes the significant level of care these patients often need. AltaMed will also work with the participants to determine if a set meeting day and time would be beneficial to their ongoing care. By using a team-based and phased approach, AltaMed will be able to provide these services as noted above.
Within the City of Vernon’s Hub “Health Bungalows” and through referrals, AltaMed will administer comprehensive behavioral health services (co-occurring mental health and substance use disorder (SUD) On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 5 | Pag e treatment), HIV care and treatment, and crisis intervention. AltaMed’s Behavioral Health department supports community members with intervention programs serving ‘mild to moderate’ cases with screenings that may treat depression, anxiety, chronic medical condition, postpartum depression, and recently diagnosed patients (with conditions like HIV and diabetes). AltaMed will utilize the Vernon Health Bungalows to in order to expand access to behavioral health services and co-occurring mental health and substance use disorder (SUD) services. AltaMed will deploy its behavioral health clinicians to conduct the following activities at the centralized hubs: client scheduling, in-take, and assessment for referrals in order to identify patient need to appropriate interventions, and provide linkages to additional care. All patients, 18 years old or older, will be screened during their annual visit using the Alcohol Use Disorders Identification Test (AUDIT-C and AUDIT) and Drug Abuse Screening Test (DAST-10). If patients screen positive, on the AUDIT or DAST-10 (see Attachment 2 for details on scoring), patients will receive Brief Intervention and a referral for substance abuse treatment (at AltaMed), which may include medication assisted therapy for alcohol or opioid misuse. Patients identified through the screening process or through the EPIC records will be referred to the MAT program, beginning with the Case Manager who can link the patients (through a Vidyo Telehealth visit or scheduling an appointment) with the Clinical Pharmacist who will conduct an appropriateness screen. After the initial intake, patients may be connected with a MAT provider and Behavior Health (BH) services, which may be provided in one of AltaMed’s clinics or through telehealth services depending on the patients’ location.
HIV Care and Treatment
AltaMed’s HIV programs is one of the most robust providers of sexual health testing and training in LA.
With more than 20 years’ experience funded as a provider through HRSA Ryan C White federal program for HIV services, AltaMed has a robust workflow for in-community testing for HIV, Hepatitis, several STDs and TB. A member of the HIV team will work with the PCC team to ensure that these services are provided for unsheltered patients as part of the PCC protocol. If positive, the Case Manager will help to link the patient to ongoing clinical support and treatment for these conditions. As an FQHC, AltaMed also has several co-located pharmacies in its clinics which qualify under to 340b program to provide low and no-cost medications to patients in need. These services will be leveraged to support participants in the PCC pilot. AltaMed will develop and execute the following services in partnership with the City of Vernon:
• Provide in place testing for HIV, Hepatitis and TB
• Provide linkages to HIV Team for positive test outcomes, • Provide ongoing education and harm reduction support to reduce the spread of these illnesses • Provide linkages through the HIV Team to peer support for participants with positive diagnoses • Develop standardized testing protocol to capture key conditions such as gonorrhea, chlamydia, Mpox, etc. and test for them with rapid results (through AltaMed’s clinics and contracted lab Quest Diagnostics)
Co-occurring mental health and substance use disorder treatment & Withdrawal management programs MAT is the combination of FDA-approved medication, counseling, and behavioral therapies to provide a "whole patient" approach to the treatment of opioid, alcohol, and other substance use disorders. MAT is currently available at 11 AltaMed Clinics in Los Angeles and Orange County for opioid and alcohol use disorders. AltaMed will leverage its clinic locations with trained MAT physicians to provide telehealth services for patients with SUD and OUD needs. AltaMed will develop and execute the following services in partnership with the City of Vernon:
On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 6 | Pag e • Integrate Behavioral Health and MAT services into Vidyo telehealth services for primary care and behavioral health follow up
The overall goals of this program are to provide increased community and internal awareness of the integrated portable clinic that will be providing services on site in the community, increased number of patients identified for services through direct community outreach and in-clinic referrals of individuals who have documented homelessness, increased access to mental health services for underserved individuals and increase individual access linkage to additional services such as food banks, housing, alcohol use disorder/substance abuse disorder services, a higher level of care for mental health, regional center, or a permanent medical home to receive additional health services. AltaMed anticipates to service the following number of unduplicated client interactions through the course of this partnership:
• Year 1: 500 - 1,000
• Year 2: 1,500 – 3,000
• Year 3: 2,000 – 5,000+
Coordinate with community partners, law enforcement, and outreach teams AltaMed has an extensive history of collaborating with outside agencies/organizations to support our patients. Relevant to this proposal, AltaMed has included a list of CBOs that it can anticipate to coordinate with in the event of additional linkages: Alma Family Services, Mela Counseling Services Center, SoCal Alcohol and Drug Programs, MAT Provider Aegis Treatment Centers LLC, LA CADA, Vernon Police Department, LA County Fire Department. AltaMed has history working with the following CBOs around housing navigation and unsheltered populations: The Whole Child, Union Station, LAHSA homeless outreach, PATH, HOPICS, Inner City Visions, Salvation Army Whittier, Salvation Army Mental Health shelter on Washington, Bell Shelter, Safe Parking, LACDA, HACLA, Cerritos Mental Health, Exodus outreach, Shower of Hope, Tiny Homes Montebello, Serenity Homes Baldwin Park, People’s Concern, Whittier First Day, American family housing, Volunteers of America LA, Weingart Center, LA Family Housing, Department of Health Services, Department of Mental Health, Harbor Interfaith, Catholic Charites, Jovenes, Union Rescue Mission, Proyecto Pastoral , Guadalupe Homeless Project, First to Serve, Multiservice Center Long Beach, St. Joseph Center, Foothills Aids Project, HOPWA, SRO Los Angeles.
Data Collection and Reporting
As the largest non-profit Federally Qualified Health Center in California with over 45 years of experience operating primary care clinics and managing related programs for its safety-net population, AltaMed has built and sustained an administrative, clinical, and fiscal infrastructure with the capacity to successfully implement and manage the requirements of this program. These systems support the effective and costefficient utilization of grant funds and ongoing project management to ensure the timely completion of program goals. AltaMed maintains a combination of proprietary software and leading industry software, such as EPIC, to streamline data collection, tracking and reporting. By deploying the PCC team with iPads that link to EPIC, they will be able to complete assessments, document encounters, make referrals, link to telehealth visits, and document outcomes from screenings, etc. at the point of care. In addition, AltaMed in now part of LANES, which is a health exchange system that allows AltaMed to access health information for shared patients with the LAC+USC County hospital systems to assess if patients have recently been admitted and discharged from an LA-based hospital. AltaMed has worked extensively with local, state and federal programs and as a federally qualified health center, is well versed in measuring, monitoring and On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 7 | Pag e reporting data, especially related to grant funded activities. With effective data collection at the point of contact (complete patient consent forms, accurate demographic information entered into EPIC, etc.), AltaMed ensures progress toward the program goal is effectively tracked and reported. AltaMed will collect and report on a semi-annual (six month) basis to The City of Vernon:
• Total number of clients served
• Client demographic information
• Number of clients receiving services by service type, client demographics, and service delivery type (i.e., point of care, referral):
o Primary health care services,
o Low-barrier SUD treatment services,
o Infectious disease services, including prevention, testing, and treatment services o Mental healthcare services,
o Harm reduction services
o Case management and other support services
• Number of services rendered by service type and service delivery type (i.e., point of care, referral):
o Primary health care services,
o Low-barrier SUD treatment services,
o Infectious disease services, including prevention, testing, and treatment services, o Mental healthcare services,
o Harm reduction services
o Case management and other support services
• Number of harm reduction supplies (i.e., overdose reversal medications and fentanyl test strips), HIV test kits and viral Hepatitis test kits purchased with SAMHSA funds as well as the number of positive HIV and viral Hepatitis tests.
• Referrals and linkages to follow-up care
AltaMed will work with the Grant Manager to complete a Behavioral Health Disparities report on a semiannual basis to the City of Vernon. AltaMed will also submit a semi-annual progress report, documenting best practices, lessons learned, and challenges encountered.
The health outcomes of these results will be measured by EPIC EHR, GPRA-CSAT. AltaMed will measure program success against the following benchmarks:
• Increase in the number of unsheltered patients with access to primary care services • Increase in the number of unsheltered patients with access to behavioral health, substance use and MAT services
• Increase in the number of patients with access to HIV, Hepatitis, and TB testing and services • Increase in the number of patients with access to social services (housing placement, food services) • Increase in the number of patients receiving MAT services AltaMed anticipates developing annual program reports, discussing lessons learned, peer-reviewed publications on program outcomes, and best practices for replication. AltaMed will be happy to disseminate this information with the City of Vernon and other community partners in order to share learnings and best practices for a PCC model of care.
On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 8 | Pag e General Scope of Work
Through AltaMed’s Portable Clinical Care model, with integrated behavioral health and HIV care, AltaMed seeks to promote and increase awareness of the PCC model in the community and on site at the City of Vernon’s “Health Hubs”, provide direct on-site and in-place clinical services, and provide service linkage to additional resources, such as food, housing placement, long term mental health, or a permanent medical home to receive additional health services.
Through the scope of this 3-year partnership, AltaMed will conduct the following activities, in order to display an increase in access to these critical services:
• Hub Services that include primary care, behavioral health (with co-occurring services to include substance use disorder (SUD) treatment/withdrawal management programs), HIV care and treatment, and linkages to additional providers.
o AltaMed will operate a centralized service location within one City of Vernon’s Health Bungalow. This site will serve as the primary service site for patient needing primary care and linkage to additional services. Staffed with a primary care provider, community health worker, and behavioral health case manager, patients will receive on-site basic primary care services (including wound care, acute infection follow up, vital sign monitoring, screening for high blood pressure and diabetes), mental health and substance abuse screening, HIV screening and case management services to address social determinants of health including housing and coordinate all aspects of care (behavioral health, primary care, infectious disease and supportive services). As needed, patients will be referred to a social worker for appropriate interventions and case management support services, as well as AltaMed’s large network of primary care clinic sites, specialty services and high-risk patient programming— Clinician Home Visit Program, Enhanced Care Management, and Care Navigation for Unsheltered Patients.
• Spoke Services that include day patient care in the field, routine health services and education, case management, and referrals to additional providers.
o AltaMed will staff the City of Vernon’s mobile units (community outreach and service), offering outpatient care, routine health services, and referrals to specialized providers (housing, food resources, etc.). A licensed vocational nurse, case manager and community health worker will utilize the City of Vernon’s community outreach mobile unit to conduct community outreach and health education to local businesses and community members, promoting the services offered by The City of Vernon and AltaMed. Leveraging its community health status as a trusted messenger in the community, AltaMed will foster relationships with community members and begin to conduct in-place treatment and internal referrals via the City of Vernon’s mobile health unit.
• Program Administration in order to effectively establish workflows that will properly address the City of Vernon’s health needs, and allow AltaMed to ensure timely and ample services. o Through a “ramp up” period in the first quarter of the partnership, AltaMed will establish workflows for all of the services proposed, complete hire and training of care teams on integrated PCC care model + behavioral health and HIV testing, conduct thorough mapping On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 9 | Pag e exercises to target highest need encampments, intersections, and extend existing contracted relationships with specialty providers.
• Data Collection: A dedicated team, made up of a Project Director, Program Coordinator, and clinical team will be deployed to reach unsheltered, community, worker, and resident individuals in the community with the goal of increasing their knowledge and access to care. By the end of the 3- year period, AltaMed’s Program Evaluator will assess and display the following successes of the program, using programs such as our EPIC EHR and GPRA-CSAT:
o Increase in the number of individuals receiving primary care with wrap around services o Increase in the number of individuals receiving mental health, substance use and MAT services
o Increase in the number of individuals receiving HIV Hepatitis, TB Testing & services o Increase in the number of community linkages to community providers for SUD and MOUD services, behavioral and mental health, primary care, telehealth, and other services like food and housing placement.
Ultimately through this partnership, AltaMed will provide accessible, holistic healthcare to unsheltered, racially and ethnic diverse, and underserved individuals who face barriers to traditional healthcare services.
Work Plan
Ramp Up Period & Project Management (Est. start date: July 1, 2024) AltaMed’s PCC Project Director, Program Coordinator and Community Health Worker will conduct the following activities in order to establish efficient workflows for in-place and on-site care, and scale services on behalf of the City of Vernon’s health department:
• Establish and finalize the following workflows:
o PCC, Behavioral Health, SBIRT, MAT (patient assessment and follow up) o Testing and services for HIV, Hepatitis, and TB
o Linkage to additional services (housing, food, etc, working with key partners) o Health insurance screening process (Medicaid, Medicare) • Integrate universal substance use screening into our electronic health record (EPIC) • Complete hire and training of care teams on integrated PCC care model + behavioral health and HIV testing
• Extend existing contracted relationships with specialty substance use service providers and other community service providers
o Create direct linkage to peer recovery support services • Integrate Vernon mobile units and hubs within scope. Work with PFS to obtain the appropriate clearance from the State after Change in Scope has been obtain in order to bill for services, if needed
• Leverage AltaMed’s internal community affairs and branding teams in order to develop several linguistically appropriate communications pieces, including: promotion of services at hub “Health Bungalows”, health education pamphlets (to help increase awareness of OUD and other substance abuse risks, MAT services), resource guides for additional linkage to care after resources • Conduct a thorough mapping exercise to target highest need encampments, intersections, and establish MOU’s with groups serving unhoused populations On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 10 | Pag e • Deploy team, establish partnerships and referrals to other service providers and CBO’s serving this population
Primary Care at Bungalows (Est. start date: October 1, 2024) An AltaMed PCC Physician, Licensed Vocational Nurse, Case Manager, and Community Health Worker will be the primary staff involved in operationalized primary care services within the City’s Health Bungalows:
• PCC provider will rotate, 2 days a week at the Vernon location. Provider will also be made available via telehealth.
• LVN, Case Manager and CHW will be available 4 days/week at the bungalows. • Administer primary care services, preventative services, case management and health education. • Build out the necessary health information systems and business and clinical protocols and procedures, as necessary.
Primary Care at Bungalows + Mobile Unit Activation (Est. start date November 2024) AltaMed PCC Physician, LVN, Case Manager, and CHW will expand Phase 1 services by activating 2 mobile units. AltaMed will
• Administer community outreach and health education to local businesses and community members, promoting the services offered by The City of Vernon and offer screenings and treatment through Vernon’s mobile health unit
• PCC provider, LVN, Case Manager, and CHW will rotate 2 days a week at the Vernon location.
Provider will also be made available via telehealth
• PCC provider, LVN, Case Manager, and CHW will rotate 2 days a week in the field.
Primary Care at Bungalows + Mobile Unit Care + Referral Services (Est. start date January 2025) Phase 3 will serve to meet demand for complex health care needs by activating AltaMed’s referral system to specialty services and larger referral network. Staff, made up of our Program Coordinator, PCC Team Physician, Case Manager, and Social Worker will conduct the following activities:
• PCC provider, LVN, Case Manager, and CHW will rotate 2 days a week at the Vernon location.
Provider will also be made available via telehealth
• PCC provider, LVN, Case Manager, and CHW will rotate 2 days a week in the field. • Social worker will deliver therapy for mild-to-moderate cases of anxiety and depression • Case manager will coordinate clinical appointments and social service needs (food, housing) Fees and Costs
In order to develop and execute the Portable Clinic Care model, AltaMed would require $1,959,300 in funding, over a three-year period. Year one would require $659,552 in funding. Years two and three would require $649,874 in funding. AltaMed will optimize several of its clinical departments, including its Behavioral Health, Health Services Operations, and HIV departments, in order to oversee the PCC team who will provide outpatient services, outreach and necessary linkage to care. Primary costs requested from The City of Vernon include personnel, travel, and supplies (equipment and medical):
On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 11 | Pag e Personnel
• Program Director (.25 FTE) will oversee the deployment of the program, training and reporting o Not to exceed $159,075 over 3 years ($53,025 annually) • Program Coordinator (1 FTE) will work with the Project Director to develop and execute the work plan to implement the PCC protocol.
o Not to exceed $255,000 over 3 years ($85,000 annually) • PCC Team Physician (.5 FTE) will provide direct clinical services to unsheltered populations. o Not to exceed $312,000 over 3 years ($104,000 annually) • Case Manager Coordinator (1 FTE) will work with the PCC team in the field to help link patients with additional services after their initial visit.
o Not to exceed $165,000 over 3 years ($55,000 annually) • Social Worker (.25 FTE) will provide direct behavioral health services. o Not to exceed $41,250 over 3 years ($13,750 annually) • Community Health Worker (.8 FTE) will act as lead care managers to help patients address the social, medical and community problems that lead to poor health. o Not to exceed $130,440 over 3 years ($43,480)
• Licensed Vocational Nurse will provide nursing care
o Not to exceed $168,429 over 3 years ($56,143 annually) • Program Evaluator (.25 FTE) will coordinate closely with the PD to develop and finalize an evaluation and performance assessment plan.
o Not to exceed $135,000 over 3 years ($45,000 annually) • Grant Manager (.10 FTE) will support program reporting and administration. o Not to exceed $20,461 over 3 years ($6,280 annually)
• Fringe Benefits (@.28%) includes FICA, Health Insurance, Unemployment, Workers Compensation, Pension/Retirement, and Medicare
o Not to exceed $424,788 over 3 years ($141,596 annually) Supplies
• Computers (Unit cost $1,888 x 3)
o Not to exceed $5,664 in Year One
• Cell Phones (Year one $3,270, [$70/month X 12 months x 3 Staff]) (Years two & three [$70/month x 12 months x 3 staff])
o Not to exceed $8,310 over three years
• iPads for field use ($1,000 (including software licenses) x 3 Staff) o Not to exceed $3,000 in Year One
• Office Supplies (General office supplies, printing, etc.) ($192 per month x 12) o Not to exceed $6,912 over three years
Travel
• Staff Mileage: Travel from AltaMed Corporate to Vernon City Hall (480 miles per month X 3 Staff X $0.585/mile x 12 months)
o Not to exceed $30,327 over three years ($10,109 annually) • Vehicle Operational Expenses (Insurance)
o Not to exceed $30,000 over three years ($10,000 annually) Medical Supplies (Testing, Vaccination, Treatment Supplies) • In-place clinical care supplies (wound care, gloves, gauze, alcohol wipes, etc.) ($1,000/month) On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 12 | Pag e o Not to exceed $36,000 over three years ($12,000 annually) • Over the counter medications (antacids, ibuprofen, etc.) ($200/month) o Not to exceed $7,200 over three years ($2,400 annually) • Testing Kits (Roche Accucheck (test strips, lancets), Hemocue 201 (test strips), Clintech status (test kit), DCA Advantage (test kit), TB Test Kit, HIV Test kit) ($100/month) o Not to exceed $3,600 over three years ($1,200 annually) Indirect Costs: This covers 2.8% general and administrative expenses (e.g., accounting department costs, personnel department costs, etc.). Note: AltaMed's federally negotiated indirect amount is 24.5%. • Not to exceed $53,366 over three years (Year One: $17,964 and $17,701 in Years Two and Three) AltaMed will develop a long-term sustainability plan, identifying additional funding sources and direct billing mechanisms that will ensure these critical services are made available to this growing population of unhoused Latinos and communities of color to ensure culturally connected holistic care is available to them in Vernon and in the surrounding communities long-term. AltaMed would welcome the opportunity to continue to work with the City of Vernon beyond the funding period to co-identify funding opportunities that could sustain and expand operations, in pursuit of building out a robust health department in the city.
Ability of the Proposer to Perform
Experience with Similar Programs and Populations
AltaMed launched our first mobile clinic in 1999 and has operated an integrated service model for patients experiencing homelessness since 2020. We operate dental mobile units and school-based behavioral health clinics that offer dental care, vaccinations, and health screenings to the highest need neighborhoods.
AltaMed’s experience with reaching and building trust with Latino and other diverse underserved communities will enhance our PCC team’s ability to address immediate needs and provide preventive care and support services. AltaMed has been working with unsheltered populations since its inception, with the creation of a dedicated Home Care team in 2018 with the specific mandate to meet patients where they are, whether in their homes or whether they are unsheltered. As AltaMed’s patient population is primarily Latino and low income; patients served tend to experience a number of health disparities due to lack of health literacy, race, lack of access to quality primary care, and socioeconomic status.
AltaMed has experience implementing and managing large scale research and service grant projects to address gaps in care and address critical social needs for severely vulnerable and unhoused populations, including:
1. Housing Navigation Program
AltaMed’s Patients Experiencing Homelessness (PEH) team engages in patient outreach, one-on-one service navigation, case management, and in-person interventions to address housing insecurity. The robust two-person team began services in 2020 and manages an active portfolio of 280 patients. The team continued direct, in-person services throughout the COVID-19 pandemic while maintaining a 60% assistance rate. The top linkages provided have been to the Coordinated Entry System, Project Room/Home Key, health services, transportation, and various county agencies. Patients are referred to AltaMed’s PEH team by various stakeholders, such as 1). in-clinic providers, (2) AltaMed’s Clinician On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 13 | Pag e Home Visit Program that engages in street medicine and manages transitions of care for recently discharged patients, (3) and lastly, external housing navigation teams like Exodus, PATH, and LAHSA.
AltaMed serves as the patient’s medical home while partnering with external agencies to ensure seamless access to services. The PEH team works diligently to gain and maintain the trust of patients experiencing homelessness by offering to accompany patients to appointments with clinicians, service providers, and civil matters. PEH team members support patients in service navigation by routinely following up with the service provider to mitigate any barriers for the patient. Patients receive regular contact from a PEH team member, and when patients transition to permanent housing, contact is reduced to once every 3 months to ensure housing retention.
2. Clinician Home Visit Program
AltaMed manages a Clinician Home Visit Program, which involves going above and beyond to serve the complex needs of patients who are homebound or have significant barriers to managing their health and getting to their appointments. The patients in this program have had two or more hospitalizations or over four emergency room visits within the last six months. They also have one or more of the following medically severe diagnosis: congestive heart failure, chronic obstructive pulmonary disorder, uncontrolled diabetes, degenerative neuro disease, recurrent asthma exacerbation, end stage renal disease and on dialysis, wounds w/ a chronic condition or stroke. Additionally, patients with two or more of the following also qualify for the program: dementia, on multiple medications, blindness, heart disease or uncontrolled high blood pressure. The Clinician Home Visit Program is a multidisciplinary clinical team of physicians, nurse practitioners/physician assistants, nurses and medical assistants who deliver clinical care in a patient’s place of residence to remove barriers for our high-risk/seriously ill and homebound patients to reduce unnecessary and costly hospitalizations. In 2023 the team recorded 3,602 patient visits that resulted in a 30% average reduction in Emergency Department visits and a nearly 37% average reduction in hospital admissions.
3. Enhanced Care Management
In response to California’s CalAIM initiative designed to improve health outcomes for Medi-Cal beneficiaries with complex needs—including individuals experiencing homelessness, AltaMed began the build out of its Enhanced Care Management program in 2022. Since then, AltaMed has grown a robust interdisciplinary care team approach that supports even the most complex social, developmental, behavioral, and clinical conditions of socially and medically complex patients. With care teams that include Community Health Workers, Patient Care Coordinators, Social Workers, Physicians and Nurses, and ancillary staff, AltaMed provides intensive case management, personalized care plans and collaborates with community based service providers to care for the whole person.
4. Behavioral Health Integration
In 2014, AltaMed received a $500,000 grant from HRSA to integrate an SBIRT protocol for depression into its primary care protocol. Since then, AltaMed has successfully implemented the program with almost 95% of adults (143,000 adults in 2019, pre-COVID) receiving a depression screening at their first or annual visits.
5. Healthy Communities, Healthy Lives:
A $3 Million grant from the Centers for Disease Control and Prevention funded in 2014, coalition includes LADPH, Los Angeles Unified School Districts, Superior Grocers, 211 Los Angeles, YMCA On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 14 | Pag e Metro Los Angeles, and several other community agencies, to (1) increase access to healthy food options, (2) increase awareness of and access to opportunities for physical activity, and, (3) increase utilization of community programs that prevent, reduce risk for and management diabetes, obesity and other chronic ailments.
6. Integrated HIV Services
Among its 276,000 clients, AltaMed serves over 2,200 individuals with diagnosed HIV each year at four dedicated HIV primary care clinics with a strong footprint in densely-populated Latinx communities most impacted by HIV. AltaMed’s commitment to Ending the HIV Epidemic also includes its dedicated efforts to HIV prevention, reaching over 3,000 high-risk individuals each year through its evidence-based, high-impact approaches to prevention including community-based and biomedical interventions. AltaMed is a long-standing Ryan White and Minority AIDS Initiative provider with an almost 40-year history of working with its target population. In 1986, AltaMed first launched its HIV Medical Services to combat HIV/ AIDS in its own community of East LA. Its partnership with the Ryan White Part C program to deliver HIV outpatient early intervention services began a few years later through a demonstration grant from the Bureau of Primary Health Care in 1989. AltaMed has emerged as a regionally prominent HIV service provider offering vulnerable populations in predominantly Latinx immigrant communities a full spectrum of bilingual and culturally-competent prevention and treatment services in Los Angeles County. AltaMed is prepared to leverage years of programming and implementation experience---including offsite STD testing through a mobile unit —to serve City of Vernon member. AltaMed has a successful history of deploying a HIV mobile unit, using it to conduct 2,533 HIV tests in 2018 and 2,470 in 2019. In 2020, due to loss of funding and the COVID-19 Pandemic, testing moved to a storefront location in Boyle Heights, Los Angeles. As a result, AltaMed was conducted 424 tests in 2020 and 566 tests in 2021. Since that time, the department has been working hard to expand rapid testing participation. In 2023, AltaMed performed 2,616 rapid tests, an 18.8% increase over 2022 levels. This increase is a result of increased outreach and testing services in both Los Angeles and Orange Counties, establishing partnerships with community based organizations, and hosting quarterly events at our prevention site in Boyle Heights. AltaMed’s successful history of conducting offsite testing through a mobile unit at formalized partner locations, including substance abuse and mental health Community Based Organizations (CBOs), demonstrates that targeted and enhanced testing efforts to stop the spread of HIV in Los Angeles and Orange Counties must include offsite, mobile field testing with local partners as well as informal social/affinity groups.
AltaMed also has extensive experience developing and implementing programs for underserved populations from a variety of diverse backgrounds. As a large majority of the population served are immigrants and Spanish speaking, AltaMed has successfully adopted the National CLAS standards, developing a workforce the majority of whom are not only bilingual in English and Spanish, but are also familiar with the lifestyle and cultural diversity of the populations served. AltaMed also maintains a Cultural and Linguistics Specialist. This Specialist serves to educate and train the entire AltaMed staff to provide culturally and linguistically sensitive customer service. This training includes conflict management and resolution, presentation and telephone etiquette, and appropriate methods of interacting with consumers.
Demographic data, including patients preferred language, ethnicity and race are collected as part of patient clinic encounters and stored in EPIC. AltaMed conducts annual community needs assessments to understand characteristics, shifting demographics, and accurately assess needs. AltaMed receives patient feedback on services through satisfaction and experience surveys and ongoing physician surveys.
On-The-Streets Portable Clinical Care with Integrated Behavioral Health and HIV Care 15 | Pag e Staff Capacity
Each of the staff participating in this project have extensive experience serving this community. Key Personnel for the program will include:
• Project Director (0.25 FTE) Dr. Christopher Bui, has served as AltaMed’s Medical Director of Home Care Services for High-Risk Populations since 2018 and will oversee the deployment of the program, training and reporting.
• The Program Coordinator (1 FTE) will work with the Project Director to develop and execute the work plan to implement the PCC protocol. They will also manage the care team, including the Social Worker and Case Manager Coordinator, to support execution of the protocol, and help to enhance/expand the adoption of the services.
• Project Evaluator (0.25 FTE) role will be filled by Sharon Hudson, PhD, who is the Director of Implementation Science and Evaluation. The PE will coordinate closely with the PD to develop and finalize an evaluation and performance assessment plan. The PE is bilingual in English and Spanish, and has over 20 years’ experience in research design and evaluation.
Skills and previous qualifications for key personnel are below, and professional resumes are included in this proposal:
Project Director: Dr. Christopher Bui is Associate Chief Medical officer of Senior and Complex care at AltaMed. Dr. Bui has over 15 years of experience providing medical care to patients with severely complex clinical and social needs. As a Physical Medicine & Rehabilitation specialist and Palliative Medicine fellow, Dr. Bui is well versed in service complex populations and developing innovative clinical programs. As a Director of Outpatient Palliative Medicine at Kaiser Permanent, he led the operationalization of a new clinic for geriatric patients.
Dr. Sharon Hudson is the Director of Implementation Science & Evaluation at the AltaMed Institute for Health Equity. Dr. Hudson has over 25 years of experience as a Behavioral Scientist, responsible for designing and implementing programs and research studies in primary care, specialty care, and communitybased health. Currently, Dr. Hudson serves as AltaMed's lead evaluator on two SAMHSA-funded programs: La Linterna (a multi-disciplinary clinic for recently immigrated youth and their families), and the medication assisted therapy (MAT) program for individuals with opioid use disorder or alcohol use disorder. AltaMed has provided an abbreviated CV for her, keeping the page limits of this RFP in mind.
For a full professional resume that includes her professional appointments, honors/awards, teaching, service, research/scholarship, and full list of publications, please email Tatiana Acosta at [email protected]