In April 2025, a partnership began between Health Net, Dignity Health, and Vivant Health in Sacramento County. They focused on high-risk Medi-Cal members. This group often needs many healthcare visits. The partners worked together by combining medical knowledge and social support services.
Health Net, part of Centene Corporation, manages the Medi-Cal health plan to make sure patients get care when needed. Dignity Health runs hospitals such as Mercy San Juan Medical Center and Methodist Hospital of Sacramento. Vivant Health has a large network of providers focusing on population health. Together, they used their strengths to build a care system aimed at lowering hospital visits, using resources wisely, and helping patients get better.
Key results from this partnership show what teamwork can do. In the first year, avoidable hospital days dropped by over 400. This saves money and helps ease crowded hospitals, a common problem in many places. After patients left the hospital, follow-up visits increased from 76% to 96%. Follow-up care is important because it helps prevent patients from coming back to the hospital. Mental health and substance use treatment visits went up by 20%, which is a big gain for Medi-Cal patients who often have trouble getting these services.
Cutting down avoidable hospital days matters to hospital managers and medical practice leaders. It affects how many beds are free, how staff are used, and how smoothly the hospital runs. If hospitals lower unnecessary stays, they can focus on patients with more serious needs. This also improves how patients move through the hospital and cuts wait times.
Follow-up visits are just as important. Good follow-up lowers the number of patients who must return to the hospital. Some payment plans reward hospitals for this. Moving from 76% to 96% follow-up means more patients get ongoing care, which lowers risks. For managers, better follow-up means better care and happier patients.
Mental health and substance use care is also key. The partnership shows that social factors affect health. By making these services easier to get, providers help reduce hospital visits caused by untreated mental health issues.
California’s CalAIM program seeks to improve Medi-Cal by offering more home and community services and fixing inequities. The Sacramento partnership works closely with CalAIM goals by combining clinical and social support to meet the state’s rules for fairness and quality.
CalAIM asks healthcare groups to better coordinate care in communities. This means having systems that share patient information quickly and manage communication across groups. The Sacramento team uses care teams that help with housing, transportation, and other social needs. This shows how partnerships can meet these extra demands.
Healthcare IT managers must understand programs like CalAIM. These often need new tech to help share data. Good data sharing helps providers work together and stops patients from falling through gaps. It’s also important to think about growth since partnerships need funding and training to keep good results as they grow beyond Sacramento.
Reducing over 400 avoidable hospital days in the first year shows the financial and operational benefits of coordinated care. Hospitals often have many patients in beds, which strains space and staff. This can lower care quality.
By focusing on high-risk patients and making sure they move smoothly from hospital to community care, unnecessary admissions drop. This fits with value-based care, where providers get rewards for better health results, not just more services.
Hospital leaders running these partnerships must watch savings and patient flow. Avoiding needless hospital stays saves money and lets nurses and equipment be used better.
Successful groups focus on social factors that affect health. The Sacramento team has nurses and care workers who help patients with things like stable housing and getting to doctor visits. This helps remove barriers that can cause bad health.
Dr. Keith Andrews of Vivant Health said that dealing with social issues changes how care is given. For example, if patients can’t get to appointments, they risk getting sicker or ending up back in the hospital. Fixing these problems helps patients get the ongoing care they need.
Medical managers can use this idea when making care plans. While medical treatment is important, adding social services offers a fuller way to lower hospital visits and improve health over time.
Centene Corporation, Health Net’s parent company, has seen steady stock growth because of its focus on Medicaid managed care. The success in Sacramento shows investors what companies working on value-based care and population health can do.
Healthcare groups copying this model can expect clear returns as better patient care cuts costs and meets rules. Investing in telehealth, care management software, and staff training looks promising. Medical owners should watch these trends to plan deals and tech buys that support value-based care.
Technology plays an important role in making collaborative healthcare work. Artificial intelligence (AI) and automation can make admin work easier and improve communication among providers. This helps keep the progress shown by the Sacramento group.
AI tools can handle tasks like scheduling, reminders, and collecting patient info. For places like Health Net and Dignity Health, AI can answer phones automatically, reducing staff work and allowing quicker patient contact. These tools handle normal questions, confirm appointments, and route calls based on patient needs. This frees staff to focus on medical care and coordination.
AI can also study patient info to find high-risk people who need more care. Predicting problems before hospital visits helps lower avoidable stays. This matches the goal of the Sacramento team.
Workflow automation helps care teams organize patient info and spot urgent needs. Automated alerts make sure no patient is missed after leaving the hospital. This helps keep the 96% follow-up rate from the partnership.
Telehealth combined with AI gives patients easier access to medical and mental health care. This cuts down on travel challenges. Together, these tech tools support scalable, integrated care systems.
Building Partnerships: Work with community providers who focus on social needs. Combining medical care with social support helps patients and lowers hospital visits.
Leveraging Health IT: Use electronic health records (EHRs) and data sharing systems that communicate in real time. These support teamwork across providers.
Implementing AI and Automation: Use AI phone systems and workflow tools to manage patient contacts well. Automate alerts for follow-up care and keep track of patients at risk.
Aligning with State Programs: Learn and work with state Medicaid reform programs like CalAIM. Following rules can help get funding and better payment.
Focus on Workforce Training: Growing integrated care needs staff trained in care coordination, social referrals, and technology use.
Hospitals and clinics using these steps can reduce avoidable hospital stays, increase follow-up care, and better mental health service access. These are key for managing the health of groups of patients.
The Sacramento partnership of Health Net, Dignity Health, and Vivant Health shows clear improvements in hospital use and patient care. High-risk Medi-Cal patients had fewer avoidable hospital days, better follow-up visits, and easier access to mental health care. By adding social support to medical care and using technology, this model meets California’s CalAIM goals and shows financial benefits.
Healthcare leaders and IT managers can learn from these results to improve patient care and manage costs. Using AI and automation along with systems that share data well are key to success. Other areas wanting similar results can look to this model when building integrated care systems across the United States.
The partnership between Health Net, Dignity Health, and Vivant Health aims to redefine care coordination for high-risk Medi-Cal members by leveraging integrated clinical expertise and social support to reduce hospitalizations and improve outcomes.
In its first year, the partnership reduced avoidable inpatient days by over 400, increased post-discharge follow-up rates from 76% to 96%, and saw a 20-percentage point increase in patients receiving timely mental health treatment.
The initiative aligns with CalAIM by expanding home- and community-based services while addressing systemic inequities, showcasing how healthcare organizations can meet state mandates and improve patient outcomes.
Challenges include logistical and financial barriers, such as funding for post-acute care providers, workforce training, and maintaining high follow-up rates across various healthcare entities.
The partnership’s interventions have led to a reduction in avoidable inpatient days, optimizing resource use and potentially easing hospital overcrowding.
Technology enhances care coordination through tools like real-time data sharing platforms and telehealth solutions, which are essential for replicating the model in other regions.
Investors can benefit from supporting companies focused on value-based care and social determinants of health initiatives, particularly those aligned with the integrated care model established in Sacramento.
By embedding nurses and care teams to coordinate transitions and address both medical and social needs, the partnership targeted factors like housing and transportation critical to patient care.
The partnership achieved a dramatic increase in post-discharge follow-up rates, rising from 76% to 96%, which is crucial for continuity of patient care.
The Sacramento partnership serves as a proven blueprint for improving care equity and could influence nationwide healthcare reform initiatives as CalAIM expands.
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