NatCon2018 Presentation: An Organization’s Incremental Journey Toward Whole Person Care: Practice Improvement in Real Life


In 2010, Telecare began a journey to Whole Person Care, bringing greater focus on healthcare and substance use services into our behavioral health programs. 

With limited resources to draw upon, we needed to be cost-conscious and choose approaches that offered the greatest impact and leverage.

In April 2018, we shared our journey and lessons learned in an iPoster session at NatCon18.

View a PDF of the Presentation

Download our natcon iposter session by clicking the image above.

Download our natcon iposter session by clicking the image above.

Workforce Development

As we began to develop our Whole Person Care plan, we found that we needed to address the training challenges of our geographically diverse and multidisciplinary workforce. Telecare has nearly 3,500 staff spread over seven states and a very diverse workforce of behavioral health providers and nursing staff. The entire range of our staff needed to understand the importance of whole health as well as have knowledge of co-occurring substance use and chronic health conditions, and be able to use tools to engage clients and enhance motivation through stage-matched conversations. To address this, we developed an 18-hour Whole Person Care eLearning program that covers stages of change, substance use and addiction education, as well as significant facts on chronic health conditions, culminating in an earned certificate. 

Clinical Practice Improvement

We needed to update and enhance our current clinical practices to include whole health education and lifestyle modifications, as well as explore clinical models for coordinated care that improve outcomes and reduce costs for customers. 

Our Co-Occurring Education Groups (COEG) were developed to reach people in pre-contemplation and contemplation stages of change around substance use. We also created “Smart Sets”: Decision trees that enforce key elements of health integration and identify touchpoints for motivational enhancement. We also partnered with customers to build new coordinated care clinical models that improve outcomes while reducing costs. We tested and refined new processes and then disseminate them broadly to the rest of our programs. Finally, we identified several interdependent evidence-based practices and developed a clinical framework to bring them to staff, matching the critical skills to staff roles and client acuity levels. 

Client Education

The people we serve often do not understand their high-risk physical health conditions, nor do they have fact-based information on the effects of substance use on their health. To assist our mental health providers in regularly educating and engaging clients in conversations around their health conditions, Telecare created easy-to-read, visually-engaging handouts that present a range of whole health topics, including blood pressure, body weight, diabetes, and asthma. The handouts provide education on facts and effects about each condition and offer suggestions for how to manage or prevent the condition. They also inform and empower clients by suggesting lifestyle changes that can directly improve their health and wellness. 

Staff have reported increased confidence initiating conversations by using these handouts, and clients report that they are learning information about their conditions for the first time. We have translated these handouts into six threshold languages to increase accessibility. Our workforce benefits from the handouts as well: staff report that they are using the handouts to learn about and manage their own chronic health conditions. 

Initial Outcomes

Telecare’s Partners in Wellness, the first mental health Pay for Success program in the nation that incorporates our Whole Health tools, is surpassing its success targets, with excess savings of more than $500,000 in the first year. Another program, Inland Empire Health Plan (IEHP), a population management program for high utilizers, has shown statistically significant reductions in psych inpatient, psych ER, medical ER, and IOP utilization, as well as increased contacts with their primary care physicians. (See poster for more details.)

Lessons Learned

We have learned that the following practices greatly enhance our ability to integrate Whole Person Health into our programs:

  • Educating our senior leadership team first. Senior leaders must fully understand and be "on board" with new practices and clinical models before roll-out to the company at large.

  • Engaging all staff to see health equity as a social justice issue, which helps us advocate for the people we serve.

  • Communicating clearly and consistently to ensure comprehension and buy-in from staff.

  • Adapting plans as funding appears and disappears; being nimble allows us to keep up with changes in the healthcare environment.

  • And finally, remembering that small steps matter! Sustaining momentum is important when introducing and learning from new models of care.

More Information

Download our natcon iposter session by clicking the image above

Download our natcon iposter session by clicking the image above

Telecare Whole Person Care Brochures and Information

COEG Resources

NatCon 2018 Presentation: Pay for Success

In 2017, Telecare opened the nation's first mental health Pay for Success (PFS) program in Santa Clara County, California, called Partners in Wellness.

At NatCon2018, Telecare hosted a lunch and learn presentation sharing initial results from our PFS program, an overview of the PFS model, a clinical overview of the program, and learnings for other systems interested in possible implementation. We are pleased to share the presentation and findings below.

Alternative Payment Models:
Pay for Success

Initial Results


In the first year of operation, Partners in Wellness saved more than $508,482 above the target savings. The program reduced usage well over the target rate for all services, including 81% over the target of psychiatric emergency services visits and 100% over the target for state hospital days. Significant clinical results were also shown: after a year, people with higher depression, psychosis, and drug and alcohol use scores showed significant improvement over time. Anxiety levels (measured through screenings) also improved, as well as physical health measurements such as HDL-C scores. 

PFS Model Overview

Telecare's Partners in Wellness program is an innovative six-year, performance-based contract to deliver publicly-funded services. Telecare is at risk to deliver the savings targets outlined in the contract by reducing clients' use of psychiatric hospitals, psychiatric emergency services, state hospitals, and other mental health services while also ensuring each client’s whole-person wellness. The performance targets are set to fully pay for the program (in savings) and return additional savings at the end of the six years. Dr. Keith Humphreys of Stanford University objectively evaluates the program results. From the RFP process beginning in December 2014 through the January 2017 official launch of the program, more than two years of work went into the development of this program. 

What's Different About Pay for Success?

Pay for Success programs, including Partners in Wellness, include several areas of additional measures and tools, and a higher degree of data analytics, than other programs typically provide. (Click on the chart to the right to see an outline of some of these differences.)

PFS Clinical Model Overview

The clinical care model for Partners in Wellness uses several tools to engage with consumers, also known as partners, on multiple fronts. Physical and mental health are measured through screenings and assessments, and a "whole health" care plan is created in partnership with the persons served. From there, the multidisciplinary team — including several peer specialists — works with the partner to ensure they have adequate housing, medications, physical health supports, care coordination, and assistance in developing recovery tools as they work toward their wellness and recovery goals. Data from health measures and a daily "Wellness Snapshot" are entered and used to produce a Huddle Report that prioritizes the team's treatment and intervention planning in their morning huddle. A monthly report tracks partners' progress over time. Treatments are adjusted as needs change. 

Lessons Learned

One of the most important lessons we have learned in our first year of operations is how crucial it is to have a firm understanding of the community in which we are working, as well as strong relationships within that community. Factors such as other community resources, housing costs, and Conservator or Public Guardian Policies can all make a big difference in the outcomes of Pay for Success programs like Partners in Wellness. 

More Information


Director of SUTS: Scott Madover

To help us better address co-occurring conditions company-wide, we appointed Scott Madover, Ph.D., to take on the role of Telecare’s Director for Specialty Product Services, Substance Use Treatment Services (SUTS).

"We knew we really needed to focus on substance use, and ensure that we were capable and doing our very best to meet those needs. We thought the best way to do that was to hire a dedicated leader, and that's Scott Madover," said Faith Richie, SVP of Development at Telecare.

In addition to working with the Development and Operations departments at Telecare to create plans for how co-occurring programming could better serve our clients, Scott will also assist with Telecare’s planning efforts so that our services are aligned with parity requirements and SUTS funding in multiple states. He will also ensure that Co-Occurring Education Groups (COEG) curriculum is available at all our product types, and recommend new standards for our existing programs so that they are co-occurring capable.

Scott’s clinical training and program leadership experience coupled with his wealth of knowledge in co-occurring disorders positions him very well for this role.

Before accepting his role as the new SUTS Director, Scott has helped lead many of Telecare’s integrated care efforts, including the development and roll out of COEG, our first company-wide substance use education program, and the design and implementation of Telecare’s first pay for success program. He also helped design and oversee the CHANGES program, our first program specifically designed to support people with co-occurring mental illness/substance use needs. Scott has also served as Regional Director of Operations in the Bay Area. 

Telecare Partners in Wellness Open House

Click here to watch the open house celebration for Telecare's Partners in Wellness program.

The Telecare Partners in Wellness program, along with the County of Santa Clara and Third Sector Capital Partners, Inc., hosted an open house for community stakeholders and members on February 8 at their new facility in San Jose, CA.

"Telecare opens many new programs, but this has been a unique experience in terms of the level of effort invested by so many parties to launch this innovative model,” said Anne Bakar, President and CEO of Telecare. "We are thrilled to have been chosen by Santa Clara for this important work. It is in perfect alignment with the value we place on public/private partnerships as the industry shifts toward performance-based funding.”

Opened on September 14, 2016, Telecare Partners in Wellness is the nation's first mental health focused Pay for Success (PFS) project. The program aims to provide community-based mental health services to individuals in Santa Clara County who have a severe mental illness, with the goal of measurably improving wellbeing and quality of life while reducing more costly service usage, including the psychiatric emergency room and inpatient psychiatric settings.

PFS is a performance-oriented contracting model that drives government resources toward social programs that best provide results to the people who need them most. Through this model, Santa Clara County has contracted Keith Humphreys of Stanford University, who is conducting a rigorous 6-year evaluation of the program.

“With this project and our prior Pay for Success project, the County is better defining our objectives in serving vulnerable populations, and is creating incentives that ensure service providers achieve those objectives,” said Chief Assistant County Counsel Greta Hansen. “Through the evaluations of each program, we will have a much better understanding of how to further increase the impact of these and other programs going forward.”

Toni Tully's Quote.png

Speakers for the event included Anne Bakar, President and CEO of Telecare; Greta Hansen, Chief Assistant County Counsel for Santa Clara County; Kavita Narayan, Deputy County Counsel for Santa Clara County; Toni Tullys, Director of Behavioral Health Services for Santa Clara County; Miguel Marquez, Chief Operating Officer for Santa Clara County; and Caroline Whistler, President and Co-Founder of Third Sector Capital Partners, Inc.

We welcome the chance to participate in this innovative partnership with Santa Clara County and Third Sector, and are honored to have the opportunity to provide services in a new area.

Pay For Success in Mental Health Weekly

First PFS Initiative to Focus on Those Living With a Mental Illness

Telecare's Pay For Success (PFS) project has been featured on page one of Mental Health Weekly’s October 26 issue. PFS is Telecare's opportunity to share what we learned about people with mental illness and complex challenges.

The Santa Clara PFS program is being designed to serve residents with acute mental illness, who are among the highest users of the county's psychiatric emergency and inpatient services. It is a funding model where the government pays for services only if a service provider, Telecare, achieves clearly defined results.

"For this group, we anticipate reducing their predicted use of these acute and costly services by 35 percent," said Faith Richie, Senior Vice President of Development at Telecare.

Toni Tullys, MPA, Director of Behavioral Health Services at the Santa Clara County Health and Hospital System, praised Telecare’s impressive track record of developing programs that aim to reduce hospital stays, saying that Telecare has "the expertise of working with individuals with very high needs and developing, designing, and implementing services to support the needs of that population."

"We’re bringing government and philanthropy and the private sector together with the unique focus on innovations and outcomes," said Anne Bakar, President and CEO of Telecare.

Preliminary design and planning work is being done now. The program is scheduled to launch in 2016.