County of Santa Clara Health System Awarded for Helping Cognitively Impaired Avoid Cycle of Incarceration

In-reach Program Wins Quality Leader Award from California Association of Public Hospitals and Health Systems and California Health Care Safety Net Institute

Santa Clara County, Calif. December 13, 2023 – The County of Santa Clara Health System has received the prestigious 2023 California Association of Public Hospitals and Health Systems (CAPH)/California Health Care Safety Net Institute (SNI) Quality Leaders Award (QLA) for their entry “An Integrated Transitions of Care Model for Vulnerable Populations: Developing Best Practices and Closing Gaps for Justice Involved Individuals with Executive Function Disorders.”

The in-reach pilot program is a cross-departmental initiative partnering with the County of Santa Clara’s Behavioral Health Services, Custody Health Services, and Technology Services and Solutions designed to address system gaps and health disparities for justice-involved patients who may benefit from a tailored approach for assessment and treatment planning upon discharge based on knowledge about executive function disorder (EFD).

“Santa Clara Valley Healthcare realizes the unique challenges many of our community members face and is committed to helping everyone achieve the best possible healthcare,” said Paul E. Lorenz, Chief Executive Officer for Santa Clara Valley Healthcare. “The teamwork of everyone in Behavioral Health Services, Custody Health Services, and Technology Services is what made this award possible.”

Those with EFD experience higher barriers to social determinants of health and are often limited in their ability to secure housing, employment, accessing primary care, mental health services, and are less inclined to adhere to treatment plans following discharge from custody.

“EFD patients have impairments and deficits that cannot be seen visually and represent an especially vulnerable population needing advocacy and active care coordination,” says Dr. Huy Ngo, Special Populations & Transitions of Care Medical Director. “They face serious challenges both prior to, during, and post-incarceration, and can frequently cycle between institutions while struggling to establish independence.” 

The CAPH/SNI QLAs showcase their members’ most outstanding efforts to advance high-quality, equitable health care for Californians and include four categories of awards: equity, population health, care redesign and innovation. The goals of the QLAs are to highlight forward-thinking and innovative approaches in California’s public health care systems and to encourage the spread of effective strategies that improve and advance high-quality, equitable health care.

SCVMC received the QLA award for Innovation with their Integrated Care Team (ICT) pilot program. The program looks at patients that have significant cognitive impairments going through the carceral settings and having higher utilization of the health system.  ICT consists of a physician-led multidisciplinary team including a community outreach specialist, rehabilitation counselor, nurse practitioner, and licensed vocational nurse.

“We are finding the gaps in care where people fall through the cracks so that we can support them in sustaining their optimum health in community, decreasing recidivism, and maintaining their housing and their social structure so they are able to maintain relationships as part of their healthy life,” said Michelle de la Calle, County of Santa Clara Health System’s Office of System Integration Director.

The ICT uses interventions that include cognitive assessments to evaluate a justice-involved patient’s EFD condition, which often remains undiagnosed, and determining more effective strategies to address their impairments. Patients with EFD and justice-involvement often require more support and intensive case management, resulting in improved compliance with mandated appearances and reduction of warrants and incarceration rates.

ICT patient in-reach, often within custody or hospital settings, initiates the crucial process of trust-building and rapport establishment. Utilizing a patient-centered approach, weekly case conferences are held to build an individualized transition plan to help stabilize and support the patient’s reintegration into the community.

Before patients can “graduate” from the ICT program, the team identifies and establishes connections for patients with primary care homes and case management programs that ensure the continuity of their care. An extended warm handoff model, designed to guide both the patient and their care team through this transitional phase, is implemented.

From August 2022 to August 2023, the pilot phase of the program included 20 ICT patients with successful outreach and engagement and 35 patients are in active outreach and monitoring efforts. Additional accomplishments for ICT patients include formal housing assessments resulting in new housing and/or housing stabilization, access to substance use treatment programs, and to medication-assisted therapy for substance use disorders.

After six months of ICT program support, preliminary data shows an 85% reduction of high-cost hospital utilization with a potential cost avoidance of $1.52 million.


About Santa Clara Valley Healthcare

Santa Clara Valley Healthcare (SCVH), California's second-largest County-owned health and hospital system, is comprised of three acute care hospitals, Santa Clara Valley Medical Center, O’Connor Hospital, and St. Louise Regional Hospital, along with a network of primary and specialty clinics. SCVH emphasizes quality care, research, teaching, innovation, and most importantly, a focus on coordinated, compassionate and patient-centered care for every patient. Our mission is to provide high-quality, accessible healthcare and excellent service to everyone in Santa Clara County, regardless of their social-economic status or ability to pay.


News Release


©2024 County of Santa Clara. All rights reserved.