The city of Stockton, home to more than 302,000 residents and the seat of San Joaquin County in northern California, made headlines when its leaders filed for bankruptcy after the 2008 housing crash and for leading the nation in foreclosures — both the consequences of overbuilding and overspending. While the city has recovered somewhat from the economic downturn, the social problems that preceded it have persisted. More than 40 percent of residents live at or below twice the poverty level.1 One of four students drops out of high school, and many working-age adults cannot find employment.2 Stockton also has the highest crime rate of any major metropolitan area in California and one of the highest per capita homicide rates in the nation.3
Stockton is shaped by its geography, with an economy built on serving as a transit point rather than a destination. Its inland port on the San Joaquin River links the Central Valley to the Pacific Ocean. During the Gold Rush this made the city a jumping off point for people and supplies; today it’s a major transportation and logistics hub, with Amazon, Safeway, and other companies using it to distribute goods. This activity, along with the region’s dairy, fruit growing, and other agriculture, has drawn Latino, Asian, and other immigrants to the area, but has not translated into sufficient numbers of good jobs.
This case study is part of a series exploring the factors that may contribute to improved regional health system performance. It describes how leaders of Stockton’s health care organizations, schools, social service agencies, nonprofits, and the public health department have forged partnerships within and across sectors and leveraged scarce resources to expand their capacity to serve residents’ considerable needs. Stockton’s progress is noteworthy, not only because of its socioeconomic challenges, but also in light of its significant health challenges relative to other parts of the state. Rates of obesity, asthma, diabetes, and behavioral health conditions are high, and a third of adults say they are in fair or poor health or have impairments because of poor physical, mental, or emotional problems.4
Health System Performance in Stockton
Stockton is one of 306 hospital referral regions, or regional markets for health care, in the U.S. The area of 595,000 residents includes the city of Stockton and most of surrounding San Joaquin and Calaveras Counties. On the Commonwealth Fund’s Scorecard on Local Health System Performance, 2016 Edition, Stockton, along with Akron, Ohio, improved on more performance measures (19 of 33) than any other region (Exhibit 1). In comparing the performance of U.S. hospital referral regions, the Scorecard found wide variation on indicators of health care access, quality, avoidable hospital use, costs, and outcomes. The Stockton region moved from 156 to 92 in ranking based on improvements in all four dimensions of health system performance.
Collaboration Across Sectors to Reach Vulnerable Populations
San Joaquin County, like much of the Central Valley region in California, has fewer resources to invest in social services than do neighboring counties. Leaders of health and social service organizations must therefore work together to meet residents’ needs, says Margaret Szczepaniak, assistant director of San Joaquin County’s Health Care Services Agency, which oversees public health, veterans health, correctional health, and other agencies. “In order to make these services work in this community, we’ve had to develop partnerships,” she says, pointing to the joint community health needs assessments as one example.
For more than 15 years, local government, health systems, the public health department, universities, community coalitions, and other groups have partnered to assess the region’s health. For the most recent assessment, partners focused on social determinants of health — economic security, affordable housing, effective education, personal safety, and healthy environments — to explore the root causes of health disparities. “We see those issues as cross cutting,” says Tammy Evans, director of San Joaquin County’s public health department.
Promoting Healthy Starts
Another collaboration — involving the public health department, federally qualified health centers (FQHCs) and other clinics, the nonprofit First Five San Joaquin, and local hospitals — has successfully promoted breastfeeding as a way to kick-start healthy development.5 Through this effort, three of Stockton’s five maternity hospitals (San Joaquin General, Lodi Memorial, and St. Joseph’s) have earned “baby-friendly” designations for their efforts to encourage breastfeeding among new moms by keeping mothers and newborns together, providing anticipatory guidance, and other efforts.6 (Just 347 hospitals in the U.S. have earned this recognition, among some 3,000 maternity hospitals.7)
San Joaquin General’s efforts to become baby-friendly took nearly a decade of culture change, including retraining nurses and other staff and weaning this county hospital off of the financial support it had received from companies that had been allowed to distribute free formula samples. “This recognition really speaks to the hospital’s commitment to do what is right for mothers and babies and not follow the dollars,” Evans says. Breastfeeding rates among infants born there have risen from 5 percent in 2006 to 74 percent in 2016.8
In a related effort involving the public health department and local hospitals, the Black Infant Health program offers support to pregnant African American women through their baby’s first year of life. In San Joaquin County, as in many other parts of the nation, black babies are much more likely than white babies to be born prematurely — likely related to stress, poor diet, chronic disease, lack of timely prenatal care, and other factors.9 Women receive home visits by public health nurses and join group educational classes on topics such as building self-esteem, coping skills, and nutrition. Many continue to meet after the classes end, and three-quarters of those from the most recent group tried breastfeeding or are still breastfeeding six months after delivery.10
Using Schools as Pathways to Health
Stockton’s leaders use schools as pathways to bring services to hard-to-reach populations, including teens and undocumented immigrants. Three of Stockton’s large urban high schools include health clinics run by Delta Health Care, a local nonprofit. Part of the impetus for creating the clinics in the early 1990s was to bring family planning services to Stockton’s teens, who at the time had the highest teen pregnancy rate in the state.11
The clinics are sustained through a combination of philanthropy and volunteerism: schools donate the space; Delta raises funds to pay for health educators and a part-time physician and nurse, who deliver services free of charge; medical students volunteer time; and behavioral health staff — including therapists, social workers, substance abuse counselors, and anger management counselors — are able to bill Medicaid for some of the services they provide.12
A key function of the clinics is to bring behavioral health services to at-risk teens: in 2016 half of Stockton’s 11th graders reported having used drugs and 15 percent said they were involved with gangs.13 Teachers or friends can refer students to the clinics’ behavioral health providers when they notice mood changes, deteriorating hygiene, or other signs of concern, and students can walk in to see them at any time. Clinicians also use physical check-ups as opportunities to engage students about other issues. “They come in because they want to be able to play a sport,” says Deanna Staggs, the school-based health program manager. “In the course of an exam the doctor may talk to kids about tutoring if they notice their grades are poor, or grief counseling if the student has experienced a death in the family.”
The county public health department also uses schools to engage families, particularly undocumented immigrants who lack health insurance and may distrust the traditional health care system. Since 2009, the department has supplied school nurses with flu vaccines, which are given free of charge to students and their families. Tammy Evans credits this program with enabling rapid response to flu outbreaks, thereby reducing hospital use.
And a partnership between the public health department, University of California Cooperative Extension program, and the county agricultural commissioner introduces kids and their families to healthy food options in an effort to reduce obesity (29 percent of San Joaquin County adults are obese as are 21 percent of fifth, seventh, and ninth graders).14 Local farmers sell reduced-price fruits and vegetables at elementary schools — often giving kids their first taste of produce such as cucumbers, peaches, or almonds.
Complementary efforts led by the public health department and county agricultural commissioner resulted in the opening of a supermarket downtown. The public health department is also leading an initiative to bring healthy food to neighborhood bodegas by offering them financial incentives to sell healthy items, marketing assistance to help promote them, and connections with local urban farms to purchase low-cost produce.15
Stockton leaders’ latest cross-sector partnership targets South Stockton, one of the poorest neighborhoods in the city, where residents can expect to live 20 fewer years than their wealthier neighbors.16 In June 2016, Community Medical Centers, a network of 14 FQHCs, opened a clinic in South Stockton that offers primary, behavioral health, and oral health care. In an effort to wrap comprehensive services around residents, it sits within a community center that provides social services, job and legal aid, youth and senior programs, a farmers market, and life-skills classes. “We can refer our patients to these supportive services, and they can refer to us,” says Christine Noguera, Community Medical Centers CEO.
Promoting a Healthy Environment
Stockton’s leaders have also capitalized on state and local policy to promote health. California’s cigarette tax is widely credited with helping to reduce regional smoking rates, which dropped from 16 percent among adults in 2011–12 to 12 percent in 2013–14 — placing Stockton in the first quintile of performance among U.S. hospital referral regions. Leaders built on this policy by establishing smoke-free bus stops, and are now working to make other public places smoke-free. To curb child obesity, Stockton’s city council in June 2016 passed an ordinance requiring restaurants serving children’s meals to make water or low-fat milk the default beverage, replacing typical offerings of soda or chocolate milk.17
Stockton’s leaders are also working to improve the air quality. Airborne pollutants from agricultural pesticides and the many trucks driving in and out of the region become trapped by the mountains and linger in the valley, making San Joaquin County home to some of the most polluted air in the United States.18 The 2016 health needs assessment found much higher rates of asthma among both adults and youth compared with statewide averages.
State mandates are fueling local efforts to clean up the air — both to reduce the carbon footprint and improve human health. Under California’s Sustainable Communities and Climate Protection Act of 2008, regional planning agencies must develop strategies for transportation, land use, and housing policies to meet targets for reduced greenhouse gas emissions. This means, for example, that the San Joaquin Council of Governments, a regional planning agency, is seeking to limit the use of cars and light trucks through efforts to promote more compact “infill development,” creation of new rapid-transit bus routes, and other efforts, though doing so is work in progress.19 “We’re still struggling to address the links between transportation and health,” says Andrew Chesley, its executive director, “but we’re not ignoring it, as we were 10 years ago.”
There are also local efforts to create more green space — an asset in short supply in Stockton, and something residents asked for during recent town hall meetings.20
Collaboration to Strengthen Care Delivery
In addition to building bridges beyond the health care sector, Stockton’s health care organizations are working together to expand access to care and improve services. California’s Medicaid expansion and state marketplace have enabled insurers and safety-net providers to enroll many more people in coverage. From 2012 to 2014 the uninsured rate among the Stockton region’s working-age adults dropped from 25 percent to 17 percent, while the uninsured rate among children dropped from 7 percent to just 4 percent — greater gains than those made by the nation as a whole.21 This expanded coverage appears to be yielding results. Scorecard data show that in recent years fewer adults went without care because of cost and more received recommended vaccinations, though it remains a challenge to connect people to a regular primary care provider.
After the insurance expansion, Stockton’s health care providers experienced pent-up demand, and many expanded their workforce to meet it. Community Medical Centers added primary and behavioral health care staff and opened a new clinic. San Joaquin General, a 160-year-old county-run hospital, doubled the number of primary care staff at its six clinics.
Providers’ efforts to improve care have been enabled by the market dominance of the Health Plan of San Joaquin, a county-sponsored Medicaid managed care plan with some 330,000 members.22 With 90 percent of the market share in San Joaquin County and over 60 percent in Stanislaus County and long-standing relationships with nearly all local health providers — it has been in the community for 20 years — the insurer has the leverage to promote broad-scale performance improvements.
For example, the health plan has partnered with local FQHCs and other providers to ensure its members receive timely preventive care, including cancer screenings — an area of performance that stood out on the Scorecard on Local Health System Performance, 2016 Edition. In both 2012 and 2014, 76 percent of the Stockton region’s residents received recommended cancer screenings, placing the region eighth among hospital referral regions on this measure. Among other efforts, Health Plan of San Joaquin sends nurses to offer training and coaching to primary care providers.
According to Lakshmi Dhanvanthari, M.D., chief medical officer, the health plan works “on a global level down to one-on-one with members” to promote health. For example, its physician incentive program includes measures of avoidable emergency department (ED) and hospital use, and it offers support to FQHCs to provide navigation and case management services. It deploys social workers to connect frequent ED users with medical homes and address social problems that may exacerbate their health conditions. The health plan also partners with the county mental health department: when one of its members screens positive for a behavioral health issue while hospitalized, it notifies the department, which then sends a counselor to try to engage that person in services — helping ensure they are not “lost to follow-up.” And it works with a local transitions program for homeless individuals to provide respite care. The Health Plan of San Joaquin has tracked reductions in hospitalizations for ambulatory care–sensitive conditions among its members (Exhibit 2).
Hospitalizations in the region also fell among Stockton’s younger Medicare beneficiaries (ages 65 to 74), dropping from 28 per 1,000 in 2012 to 23 per 1,000 in 2014 (compared with 27 per 1,000 nationally). The rate also fell among older beneficiaries, from 62 per 1,000 in 2012 to 54 per 1,000 in 2014 (compared with 66 per 1,000 nationally).
Information and Knowledge Exchange
In another effort to build bridges among providers, San Joaquin General, which serves as the main provider of specialty care to the region’s Medicaid beneficiaries, will soon begin offering free virtual consults to primary care physicians working in community health clinics. And in 2012, four safety-net partners — San Joaquin General, Community Medical Centers, the county behavioral health department, and Health Plan of San Joaquin — used a $500,000 grant from the Blue Shield of California Foundation to launch a health information exchange.
Healthier Community Coalition
Several nonprofits, health plans, and health systems work together to address health and social problems through the Healthier Community Coalition.23 In one program led by St. Joseph’s Medical Center, community health workers canvas neighborhoods to connect people to services and offer education and resources to help them manage their conditions. In a new initiative, coalition members are seeking to treat trauma among South Stockton residents; research has found links between trauma and serious medical conditions as well as depression, substance abuse, suicide, and risky behaviors.24 Using an $850,000 grant, coalition members identify neighborhood residents who’ve experienced trauma — whether from abuse in their home or violence in the community — and offer them behavioral health and social support services.25
Leveraging Medicaid Funding
Stockton’s health care leaders are leveraging Medicaid funding to further their efforts. San Joaquin General is participating in a waiver initiative under which public hospitals receive financial incentives to transform care delivery to promote value. It is working to integrate physical and behavioral health services, manage care for those with complex conditions, and promote advanced illness planning, among other efforts.26 And San Joaquin’s Health Care Services Agency has recently received Medicaid funding to lead a Whole Person Care Pilot, in which it will coordinate physical and behavioral health care and social services for the highest service utilizers, including people with multiple health conditions, behavioral health issues, those who cycle in and out of jail, and the homeless.27 Savings derived from this effort can be used to address social needs, for example by supporting housing for the homeless. Participants are also planning to open up the health information exchange to the community-based organizations, County Correctional Health Care agency, social service agencies, and others involved in the pilot.
Supportive state and local policies lay the groundwork for local improvement. Stockton’s collaborative efforts to improve health and health care have been supported by state and local policies, most notably the 2012 Medicaid expansion, which led to dramatic gains in coverage. Local health system leaders’ rapid response to expansion — bolstering primary care capacity and making other structural changes to strengthen the system — could lead to further downstream improvements to residents’ health.
A community-oriented Medicaid health plan can facilitate efforts to improve quality and coordinate care. Stockton’s locally governed Medicaid plan has created a strong foundation for improvement and enabled collaboration among providers, who appear to be committed to serving vulnerable populations.
Coalition-building efforts can generate momentum for change. The community’s coalition-building efforts have generated the momentum and partnerships needed to attract grants and other resources. And joint community health needs assessments have cemented cross-sector relationships and developed a critical evidence base to focus partners on finding creative solutions to long-standing problems. According to Evans, after years of talking about the same issues, local hospitals’ community benefit managers — charged with guiding charitable investments — “finally got the message back to the CEOs that we need to look at something different: we can’t just try the same things over and over.”
1QuickFacts: Stockton, California (U.S. Census Bureau, n.d.).
2 The Stockton metro area has much lower high school graduation rates and lower reading proficiency among third graders than the California state average. Social Science Research Council, Measure of America, A Portrait of California 2014–2015: Stockton Metro Area Close-Up (SSRC, n.d.). The Stockton metro area’s latest unemployment rate of 7.5 percent is down from its peak of 22 percent during the recession. See Bureau of Labor Statistics, Economy at a Glance: Stockton, CA (U.S. Department of Labor, n.d.); and E. Kneebone and C. Murray, “The Nation’s Major Metro Areas Show Uneven Progress Against Poverty in 2015,” Brookings Institution The Avenue Blog, Sept. 16, 2016.
3 In 2014, Stockton ranked number one in overall crime for the state. State of California, Office of the Attorney General’s Report on Violent Crime.
4 D. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: The Commonwealth Fund Scorecard on Local Health System Performance, 2016 Edition, (The Commonwealth Fund, July 2016).
5 Breastfeeding has been associated with short- and long-term benefits, including increased mother–child bonding, decreased likelihood of children developing diabetes, and maintenance of healthy weight among both infants and mothers. See, for example, R. Shamir, “The Benefits of Breast Feeding,” Nestle Nutrition Institute Workshop Series, June 2016 86:67–76; R. R. Poudel and D. Shrestha, “Breastfeeding for Diabetes Prevention,” Journal of the Pakistan Medical Association, Sept. 2016 (9 Suppl. 1):S88–S90; F. C. Stanford, “Obesity and Breastfeeding: Exploring the Relationship,” Breastfeeding Medicine, Oct. 2016 11:411–12; and S. Bar, R. Milanaik, and A. Adesman, “Long-Term Neurodevelopmental Benefits of Breastfeeding,” Current Opinion in Pediatrics, Aug. 2016 28(4):559–66.
6 Model Hospital Policies to be “baby friendly” are promulgated by the World Health Organization and the United Nations International Children’s Fund. See http://www.babyfriendlyusa.org.
7 See http://www.babyfriendlyusa.org and American Hospital Association Survey.
8 Breastfeeding rates have also gone up at St. Joseph’s and Lodi Memorial, but at these hospitals rates were not as low as at San Joaquin General before the initiative. Data on the duration of breastfeeding among new mothers are not available. In 2011, just 16.4 percent of women in San Joaquin County breastfed exclusively after three months, compared with 23.1 percent of women in the state. By 2012, 25.3 percent of San Joaquin women breastfed exclusively after three months, compared with 26.5 across the state. See California Department of Public Health, Maternal and Infant Health Assessment (MIHA) (CDPH, n.d.).
9 San Joaquin County Public Health Services.
10 San Joaquin County Public Health Services.
11 Teenage births in San Joaquin County have been on a downward trend for the past decades, following state and national trends. See kidsdata.org, Teen Births (Lucile Packard Foundation for Children’s Health, n.d.).
12 Even though about 80 percent of the high school students are covered by Medicaid, the school clinics would have to be designated as the students’ primary care provider in order to bill Medicaid for physical health services provided there. Instead of limiting access in that way, the clinics provide all physical health services free of charge. The clinics’ behavioral health clinicians are able to bill Medicaid for some services.
13 San Joaquin County Community Health Assessment Collaborative, San Joaquin County 2016 Community Health Needs Assessment (SJC2HAC, 2016).
15 San Joaquin County Public Health Services, “Refresh San Joaquin Celebrates Healthy Retail Improvements,” press release (SJCPHS, Oct. 10, 2016).
16 Central Valley Health Policy Institute, Place Matters Initiative (Fresno State University College of Health and Human Services, n.d.); J. Goldeen, “Health Clinic Opens for Poor, Underserved,” The Record (Stockton), Aug. 20, 2016; and Dorothy L. Jones Family Resource Center (Community Partnership for Families of San Joaquin, n.d.).
17 R. Phillips, “Stockton Only Second City in U.S. to Adopt Restaurant Policy Targeting Children’s Soda Consumption,” The Record (Stockton), June 19, 2016.
18 American Lung Association in California, State of the Air 2015: San Joaquin Valley Regional Summary (American Lung Association, 2015).
19 For details, see San Joaquin Council of Governments, Regional Transportation Plan/Sustainable Communities Strategy Update (SJCOG, n.d.).
20 Social Science Research Council, Measure of America, A Portrait of California 2014–2015: Stockton Metro Area Close-Up (SSRC, n.d.).
21 Newer data show that in 2015 the uninsured rate among working-age adults dropped further, to 11 percent — better than the state (12%) and national rates (13%).
22 San Joaquin County operates under one of the six available models for Medicaid managed care plans in California: it has a “local initiative,” county organized plan, Health Plan of San Joaquin, and a commercial plan, HealthNet. See Medi-Cal Managed Care Program, Fact Sheet — Managed Care Models (California Department of Health Care Services, Nov. 2014).
23 Voting members of the Healthier Community Coalition include Catholic Charities, Community Medical Centers, Community Partnership for Families, Delta Health, Health Plan of San Joaquin, Kaiser, San Joaquin County Public Health, St. Joseph’s Medical Center, and Sutter Tracy Hospital.
24 E. L. Machtinger, Y. P. Cuca, N. Khanna et al., “From Treatment to Healing: The Promise of Trauma-Informed Primary Care,” Women’s Health Issues, May/June 2015 25(3):193–97. This work complements efforts of three FQHCs in South Stockton that offer trauma-informed care and the Operation Ceasefire initiative [http://www.stocktongov.com/government/departments/manager/violprev.html], which aims to interrupt cycles of violence through direct engagement with youth and young adults.
25 The grant comes from the California Accountable Communities for Health Initiative, which is supported by The California Endowment, Blue Shield of California Foundation, Kaiser Permanente, and Sierra Health Foundation and aims to support innovative models to advance population health and reduce health disparities. See https://www.dignityhealth.org/central-california/locations/stjosephs-stockton/about-us/press-center/initiative-to-address-trauma-in-south-stockton-receives-$850k.
26 See Medi-Cal 2020 Demonstration, Attachment Q — PRIME Projects and Metrics Proposal (California Department of Health Care Services, n.d.).
27 See Medi-Cal 2020 Demonstration, Whole Person Care Pilots (California Department of Health Care Services, n.d.).
Commonwealth Fund case studies examine health care organizations that have achieved high performance in a particular area, have undertaken promising innovations, or exemplify attributes that can foster high performance. It is hoped that other institutions will be able to draw lessons from these cases to inform their own efforts to become high performers. Please note that descriptions of products and services are based on publicly available information or data provided by the featured case study institution(s) and should not be construed as endorsement by the Commonwealth Fund.