Building a Thriving Community: Live Well, San Diego
An Insight from the 2013 Human Services Summit
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How can human services leaders use disruptions to lead communities towards a better future? Live Well, San Diego! enabled a region to come together around crises and use disturbances to spark change and innovation.

San Diego County is large, diverse, and serves as a microcosm of the country as a whole. With a population of 3.2 million, now majority-minority, San Diego is the fifth largest county in the United States and has a population larger than 20 states. The County encompasses 18 incorporated cities, many unincorporated towns, and 18 Indian sovereign nations. Its diverse geography ranges from the coast to the mountains to the desert, with high-rise urban neighborhoods and rural farms.

For a number of years the county’s Health and Human Services Agency (HHSA) has found a way to offer services “from womb to tomb,” while addressing rising healthcare costs, surging social services demands, and an increasing prevalence of chronic disease. The burden is significant: The agency serves more than 750,000 people annually.

HHSA has capitalized on key milestones in the environment – from welfare reform in the 1990s to healthcare reform under the Affordable Care Act. Using four major disruptions as a catalyst, HHSA has found ways to build new governance models, engage new partners, reframe social services, and use new technologies.

The first disruption began when welfare reform provided the county’s leadership the impetus to create an integrated agency. This new organizational structure brought together child welfare, behavioral health, public health, aging services and others into an agency with “no wrong doors” that could help families achieve self-sufficiency.

The second wave of change took place in 2004 and 2007 when the county was confronted with serious wild fires that took lives and infrastructure. These fires presented HHSA and the rest of County government with a new set of challenges including communicating with 3 million people during a crisis and serving significantly more people, immediately.

In response San Diego had to innovate, remain resilient and take advantage of new technology. By reengineering the process for web-based referrals and giving people in the field mobile devices, HHSA was able to create a Mobile Remote Workforce. These innovations allowed the county to manage the crisis and even increase productivity by 27 percent, saving more than $2 million in Medicaid expenditures. This successful response highlighted the importance of fully integrating services and prepared the agency for additional challenges came just one year later.

The third wave of change happened in 2008 with the major economic downturn. In San Diego, HHSA began to see new faces, like the assistant manager of Radio Shack who had just lost his job and was dismayed to come into a welfare office. He and his peers had a different set of expectations around customer service, and would leave disappointed by a perceived lack in service offerings. It was a significant challenge: 150,000 new people enrolled in Medicare and this new population was also coming in for food assistance.

In order to serve more people and change the perception of the system in a time of constrained resources, the county had to reframe and reform its delivery of services. HHSA Director Nick Macchione captured the challenge when he told his board, “If we took our busiest highway and we just added more onramps and brought in more people, but we didn’t improve the throughput of the highway, what are we going to get?” The county knew it had to embark on an innovation quest.

They began by looking at the root causes of service needs. They found that three behaviors – lack of exercise, poor nutrition, and smoking – cause four chronic conditions—cancer, cardiovascular disease, diabetes, and lung disease—that lead to more than 50 percent of the deaths in the county. The medical costs alone of chronic diseases were totaling $4 billion. The county leadership knew there had to be a different way—an Ecological Model that would focus on improving health and wellness, using the message “3-4-50” to help explain its approach.

With the goal of achieving the Triple Aim—providing better services at lower per capita cost and creating a healthier community—Live Well, San Diego! was born. This 10-year plan to repurpose County government’s $5 billion annual budget and to engage community partners to help all county residents become healthy, safe, and thriving set the community on its fourth wave of change.

“We have to look at this braided approach of safety and health in wellness. If not, we’re being myopic and we won’t get to our true aim.”

Nick Macchione
Director, County of San Diego (CA), Health and Human Services Agency

To achieve this new holistic goal the community had to synchronize physical health, behavioral health and social services. Different agencies began sharing data, changing their practices to focus on outcomes and holding themselves accountable for the wellness of the population. HHSA began engaging in issues like education, literacy and housing, which can develop a thriving community. The sheriff started talking about putting money into health programs and coordinating with Medi-Cal. And, new relationships developed between agencies, the provider community of more than 800 nonprofits, the private sector and other community leaders.

Through Live Well, San Diego! HHSA has reduced the maze of services and made it easier for residents to navigate the various systems. “Don,” an 84-year old resident who was in and out of the hospital and wanted to spend more nights in his own bed is one resident who has benefited from these changes. The County’s Aging and Independence Services partnered with a local medical center to pilot a new “wrap-around” service model that provided patients like Don and his family with a transition care nurse coach, a social worker and personalized web-based technology to improve the transition from the hospital to home and prevent readmissions. This new service delivery approach reduced the rate of 30-day readmissions from 12.6 percent to 2.3 percent for patients like Don and provided the model for the San Diego Care Transitions Partnership, the largest of the 100 Community-based Care Transitions Programs (CCTPs) around the country funded through the Center for Medicare and Medicaid Innovation created by the Affordable Care Act.

As another example, Live Well, San Diego! developed an innovative approach to addressing childhood obesity and low academic achievement scores. Across the county one-third of all 5th, 7th, and 9th graders are clinically obese. Recognizing the connection between strong minds and strong bodies, HHSA worked with a school district in the southern part of the county where 70 percent of children had a high Body-Mass Index. By engaging parents, the school board, teachers and students in a campaign to improve health, they have significantly reduced obesity in two years and improved the health and test scores of 800 kids.

With visionary leadership, Live Well, San Diego! has been able to engage new partners, reframe human services as a key contributor in building a healthy, safe, and thriving community, create a new integrated governance model and turn a series of crises into new opportunities. As Marc Cherna of Allegheny County observed during the Summit, “this gives us all hope that we can lead this kind of transformation and make this happen. The results are phenomenal. This is something we should all emulate.”

“...this gives us all hope that we can lead this kind of transformation and make this happen. The results are phenomenal. This is something we should all emulate.”

Marc Cherna
Allegheny County



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