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AltaMed outlines programs that reduced hospital use and improved outcomes for high‑risk patients
Summary
AltaMed described value‑based programs—VIVA Gold senior care, enhanced care management, home visits, hospitalist integration and workforce pipeline investments—that it said reduced emergency visits and hospitalizations and improved care for complex patients served by this large FQHC system.
AltaMed presented several operational strategies it uses to lower costs and improve outcomes for medically and socially complex patients, drawing on full‑risk contracting, care teams and workforce development.
Efrain Telematis, described as “UltaMed Senior Vice President and Chief Operations Officer,” described a multiyear transformation: AltaMed operates 67 clinics in Los Angeles and Orange counties, serves roughly half a million patients and is primarily Medi‑Cal‑funded. The system has layered affiliates, including a managed services organization and a delegated (Knox‑Keene) entity that can accept global risk and support contracting with plans and hospitals.
Speakers outlined key programs: • VIVA Gold Senior Care: a team‑based, lower‑panel concierge primary‑care model for older adults with higher social and clinical complexity. AltaMed reported lower ED use and fewer admissions among enrolled seniors and said the model provides same‑day access and home visits where needed. • Enhanced Care Management (ECM): case‑management teams and community health workers focused on high‑need members; AltaMed reported reductions in ED and readmissions where ECM is used but noted administrative challenges in enrollment and workforce retention. • Home‑visitation and street‑medicine teams: nurse‑practitioner‑led teams that perform home visits and outreach to high‑risk patients who cannot easily access clinic care. • Hospitalist employment and transitions: AltaMed employs hospitalists at key partner hospitals to improve discharge planning and post‑discharge follow‑up. • Workforce and pipeline investments: a residency program in family medicine, nurse‑practitioner residency, site medical director training, a nursing collaborative and other pipeline programs to recruit and retain bilingual clinicians from the communities served.
Telematis and committee members said the organization’s move to capitation and risk contracts permitted targeted investments in care navigation, registries and non‑physician teams. Committee members asked about continuity vs access in the VIVA Gold model; AltaMed said patients can still see their PCP and that primary clinicians help identify patients who would benefit from the senior program. AltaMed also said most telehealth services are provided by an in‑house 24/7 telehealth team, integrated with same‑day clinic access.
Committee members praised AltaMed’s wildfire response and its flexible deployment of clinical teams during emergencies. AltaMed said it is willing to share models and data with peers and state staff for replication and learning.
