Serving as a Value-Based Care Coordinator: An Ever-Evolving Role

My name is Anisha Desai (she/her), and I grew up in the San Francisco Bay Area. I attended the University of Wisconsin-Madison, where I majored in Psychology and minored in Graphic Design. After graduating, I worked as an Emergency Department Scribe in Mountain View for 1.5 years. During my time in the emergency department, I observed how socioeconomic factors like low income levels, language barriers, and unstable housing have a significant impact on patient health outcomes and contribute to health disparities in the community. I decided to apply to the National Health Corps to serve the community and help increase healthcare access while also gaining a deeper understanding of public health and its role in improving health equity.

Value-Based Care focuses on improving patient health outcomes while reducing healthcare costs. This can be achieved through upstream interventions, such as increasing preventive care and care coordination, which help avoid unnecessary and costly medical interventions, like hospitalizations and ER visits. California’s Quality Incentive Pool (QIP) Program supports this approach by providing financial incentives to hospitals and clinics that meet specific quality of care metrics. It also aims to promote equity in healthcare by ensuring patients across all demographics achieve similar health outcomes. My host site, the Value-Based Care Team at the San Francisco Department of Public Health, partners with clinics in the San Francisco Health Network to help them meet these QIP metrics by implementing targeted quality improvement initiatives.

Each week in my position can look very different depending on our current projects and the time of year. As the end of the year approaches, we have been focusing on driving metrics that are close to their targets and in need of a final push. For example, I have been contacting patients over the phone at the Richard Fine People’s Clinic who are overdue for their cervical cancer screenings to provide information and help them schedule appointments. It feels meaningful to know that my outreach efforts not only help patients access this critical preventive health screening but also potentially secure additional funding for Zuckerberg San Francisco General Hospital, a safety-net hospital that primarily serves uninsured and publicly insured populations in San Francisco.

Our team has also started planning for next year, considering ways to improve our performance on metrics we were unable to meet this year. For example, we are collaborating with nurses and providers at the 5M Women’s Health Center at Zuckerberg San Francisco General Hospital to develop a patient survey to identify barriers to accessing prenatal care. We hope the insights gained from this survey will help us improve the timeliness of prenatal care for this population. I appreciate how value-based care prioritizes patient voices and experiences when designing quality improvement initiatives.

Another aspect of my service involves visiting clinics to shadow providers and observe prenatal appointments to understand the clinic's workflow and identify potential areas for improvement. During these appointments, I take notes and record observations, which I then share with the Value-Based Care team to inform improvement efforts. One of our team’s upcoming projects will focus on increasing the rate of prenatal and postpartum depression screenings, so my shadowing has been focused on understanding this workflow. These are some of my favorite days, as they allow me to interact directly with providers, nurses, and patients to learn firsthand about their experiences.

My service term has been incredibly eye-opening so far and has deepened my understanding of the complexities of the healthcare system. I’ve gained insight into how challenging it can be to implement change, but also how essential and impactful this work is. I’m truly looking forward to the remainder of my service term and am excited to continue learning and growing in this role!