By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When the pressure is on, we don’t rise to the occasion, we fall to the highest level of preparation.”

– Chris Voss, Author and Former FBI Negotiator

At the end of residency training, what knowledge do clinicians retain, and what tends to fade quickly over time?

Knowledge is often retained when clinicians experience a high-stakes clinical syndrome firsthand – watching it unfold, making difficult decisions, and later second-guessing whether those decisions were correct. In contrast, information is often forgotten quickly when it comes to reading about a topic they have never personally encountered.

Memories are stronger when the neuronal connections associated with that memory are more myelinated and have redundant pathways. Memories become stronger with repetition, when memories are attached to emotion, if the memory involves multiple learning modalities (listening, reading, watching, and doing), if the information is repeated over time, and if it is associated with other memories.

Some clinical scenarios are rare, but the consequences of decisions are particularly impactful. Some examples include unexpectedly being a clinician responsible for the care of a person with cardiopulmonary arrest, major trauma, status epilepticus, or obstetrical emergency.

Being relatively calm and effective in these cases depends on the level of preparation and knowledge one has gained before being confronted with an emergency. The more automatic our actions are, the faster and more accurate they will be.

Simulations and case studies are two helpful resources to help prepare for high-stakes situations. If the scenario requires a manual skill, watching a video or practicing the actual skill with some repetition is essential (simulation). If the scenario involves high-stakes decision making, a deeper and more considered thought process is helpful (case studies). Watching attentively as one of our peers struggles with the manual skills or cognitive processes of an emergency also reinforces the neural pathway; so, learning as a team is better than learning alone.

What sort of emergencies might you encounter in an outpatient practice? One of the most common is a patient who unexpectedly loses consciousness or nearly loses consciousness. First, we must quickly assess the situation to determine the underlying severity of the situation. Is it a vasovagal reaction, a hypoglycemic episode, or a cardiopulmonary arrest? Subsequently, or sometimes simultaneously, promptly initiating treatments that will help or resolve the situation is key.

Training together as a team offers other major benefits, such as: deepening trust with teammates, developing shared mental models so that the actions of others can be anticipated, and strengthening communication to be as efficient as possible in an emergency situation. In the past several months, Partnership has been sponsoring trainings in obstetrical emergencies for hospital teams and found that the enhanced team effectiveness was a major unexpected benefit highlighted by the hospitals afterwards.

Unfortunately, as our health care delivery system has moved to the convenience of online training for Advanced Cardiovascular Life Support (ACLS), Basic Life Support (BLS), etc., this becomes a missed opportunity to develop our team effectiveness, particularly with new staff. We might consider alternating or augmenting our online training with in-person scenarios to help the material resonate better and build team effectiveness. Another best practice could be to combine an in-person BLS training with clinic-specific customizations, such as treatment of vasovagal reactions, seizures, and hypoglycemia.

One final best practice is what our outgoing Physician Advisory Committee chairman, Dr. Steve Gwiazdowski, calls “high frequency, low fidelity” practice. Finding ways to do quick refreshers on key scenarios or skills every three months or so, has been proven to keep this knowledge fresh. The Banner Hospital system, with small rural hospitals throughout the rural western states, has institutionalized such quarterly re-trainings for their nursing staff and found that this approach improves both outcomes and teamwork. To better prepare for emergencies, please consider ways to incorporate these types of quick refreshers into your clinical setting.

Dr. Robert Moore, MD, MPH, MBA, Chief Medical Officer

“To be 95% confident that a large-scale implementation will be successful, look for at least four independent small-scale tests all showing a significant benefit.”

– Summary from The Science of Using Science: Towards an Understanding of the Threats to Scaling Experiments (Al-Ubaydli, List, & Suskind, 2019).

The transition of integrating back into the community after being incarcerated marks one of the most dangerous periods in a person’s life. Overdose is the leading cause of death for people recently released from incarceration, with rates more than three times the national average for incarcerated populations. Building on a 2006 pilot in San Francisco that Partnership helped expand starting in 2012, California is now poised for state-wide implementation of an approach that transforms this vulnerable transition period from a health crisis into an opportunity for healing through comprehensive, coordinated care that begins before the prison gates open.

Justice-involved individuals typically face a constellation of health challenges. In California, approximately 35,000 people are released yearly from state prisons, while most of the 350,000 people booked into county jails are released within weeks. 66% have moderate or high need for substance use disorder treatment, while incarcerated individuals with active mental health cases rose by 63% over the last decade.

The racial disparities are stark: nearly 29% of incarcerated men in California are Black, while Black men comprise only 5.6% of the state’s population. This means health care interventions for justice-involved individuals must intersect with critical racial equity initiatives.

Origins: The Transitions Clinic Network

In 2006, the pilot project at a San Francisco community health center, partnering with San Quentin State Prison, launched what became the Transitions Clinic model. This evidence-based program included innovative components like community health workers (CHWs) with lived experience of incarceration as integral health care team members.

The model proved successful and expanded rapidly. By 2024, the Transitions Clinic Network (TCN) linked 48 clinics in 14 states and Puerto Rico, including 21 in California. Research demonstrates that the TCN model cut emergency department visits and hospitalizations in half.

Partnership HealthPlan of California recognized the potential early, embracing the pilot version with strategic use of reserves more than a decade ago. The organization ultimately funded three different sites, adding two locations to the original pilot in Vallejo, demonstrating how managed care organizations could collaborate effectively to serve justice-involved populations.

Based on the proven success of multiple pilot sites in the years that followed, the Transitions Clinic and Partnership discussed expanding this model state-wide with the California Department of Corrections, even before CalAIM existed.

California Builds a Statewide Model Using Medi-Cal

Fast forward to 2023, when California became the first state to receive federal approval to use Medicaid funds for services provided to people leaving jail or prison. This breakthrough came through a federal Medicaid 1115 demonstration waiver, representing a fundamental shift in approaching health care for incarcerated populations.

The Justice-Involved Initiative is part of California’s broader CalAIM transformation. When Medicaid was created in 1965, federal law barred the use of federal funds for services for incarcerated people. California’s waiver effectively bridges this gap, allowing continuity of care that was previously impossible.

Eligible individuals can receive targeted Medi-Cal services for up to 90 days prior to release, including:

• Reentry care management services
• Physical and behavioral health clinical consultations
• Laboratory and radiology services
• Medications and medication-assisted therapy
• Services from CHWs with lived experience

Most importantly, qualifying members receive prescribed medications and medical equipment upon release, addressing the critical “medication cliff” that often leads to rapid health deterioration.

Justice-Involved Implementation and Early Success

The rollout began strategically with three pilot counties—Inyo, Santa Clara, and Yuba—on October 1, 2024. By July 1, 2025, 17 counties plus the state prison system will have launched services. For Partnership, three counties—Yuba, Sutter and Siskiyou—are included in this initial wave. Nevada County is tentatively scheduled for September 1.

Partnership’s Justice-Involved team is now seeing a steadily increasing stream of referrals coming in from ECM providers within the state prison system.

An example of how coordination of implementation is as follows: An incarcerated person with specific mental health needs and nearing release qualifies for 90-day pre-release services. They are assigned a pre-release care manager who develops a reentry plan. Before release, the individual is connected to a community psychiatrist through a “warm handoff” meeting. Upon release, the individual receives Enhanced Care Management (ECM) and subsequently gets a supply of medication to take with them.

ECM provides intensive care coordination for high-risk individuals, creating continuity that spans institutional and community settings. ECM providers address not just health care needs but social determinants of health including housing, employment, and transportation. Community Supports (CS) services complement ECM and address fundamental barriers to stability, including housing transition navigation, security deposits, and other services that promote community integration. Housing is perhaps most critical – homelessness rates among those being released from incarceration are extremely high, and unstable housing is associated with increased recidivism and poor health outcomes.

All counties must launch services by September 30, 2026. The initiative’s sustainability depends on demonstrating positive outcomes and cost-effectiveness. Success metrics include health care outcomes, community integration measures, and quality of life indicators for participants. Meanwhile, success in each county depends on local engagement activities and leadership commitment.

What Primary Care Providers Can Do

The initiative’s success ultimately depends on primary care providers’ willingness to serve justice-involved individuals effectively. Most importantly, providers must ensure that requests for initial appointments are addressed quickly. Discharged individuals typically receive only 30 days of medication and face complex medical and mental health issues. They’re at high risk of death after discharge, making rapid access to care a critical public health need.

Case managers from correctional facilities will reach out to schedule pre-release appointments. While members won’t be assigned to specific health plans while incarcerated, DHCS will make assignments retroactive to release dates. Providers should schedule these appointments immediately when requested—this transition period carries much higher mortality and recidivism rates without appropriate services.

Beyond rapid access, providers should anticipate that patients with complex needs will require comprehensive, coordinated care. This includes working collaboratively with ECM providers and community health workers, approaching patients without judgment, managing medication transitions carefully, and connecting patients to specialty care and community resources supporting long-term stability.

California’s Justice-Involved Initiative represents a fundamental shift in approaching the intersection of criminal justice and compassionate health care. Building on years of successful pilots, the state has created a model with a high likelihood of successfully spreading state-wide, which will help to transform outcomes for one of our most vulnerable populations.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Change happens by listening and then starting a dialogue with the people who are doing something you don’t believe is right.”

— Jane Goodall, English zoologist and primatologist

Disagreements about vaccinations, public health activities, and scientific research have escalated in the past few months, with an expanding chasm between the views and opinions of those with different political ideologies. Health professionals and public health leaders need to develop skills in communicating effectively with patients and members of the public who may have deeply held, but widely disparate views. Of course, this is easier said than done!

This challenge is exactly what Epidemiologist Dr. Katelyn Jetelina narrates in a recent post on her popular “Your Local Epidemiologist” Substack. She and several other famous U.S. public health leaders were invited to participate in a dialogue with leaders of U.S. Health and Human Services, Director Robert Kennedy’s, Make America Healthy Again (MAHA) coalition. Her summary of this meeting is introspective and very well-written, one of her best posts of the year. In the end, she gained a lot of understanding of the concerns and questions of the MAHA participants and found several areas of shared values.

In sharing her experience, Dr. Jetelina encourages us to find ways to have deep and meaningful conversations with those in our community who have different ideas about public health and science.

She concludes with three points:

“Fight for people, not institutions. Meet questions with empathy. Look for opportunity in the rubble— because it’s there, if we’re willing to see it. Even when it’s hard.”

Although her views expressed represent the opinions of the author and do not represent the official views of Partnership HealthPlan of California, there is value in her message for how we approach difficult conversations.

Enjoy!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only true wisdom is to know that you know nothing.”

— Socrates

Wisdom of the Elders

Tribal community members often hold respect for elders as one of their core values. This respect is shown in many ways such as allowing elders to eat first at communal meals, valuing elders’ knowledge of native languages and traditions, and listening to their wisdom expressed through stories passed down for generations.

These demonstrations of respect were evident at a cultural event recently at the Karuk Kahtishraam Wellness Center in Yreka. Teenagers and young adults watched attentively as one elder taught them how to carve traditional wooden cooking paddles. Another elder displayed his tight-weave basket[1]making skills using willow twigs and aged spruce roots. When lunch was served, tasty frybread tacos and fruit, the elders were invited to serve themselves first. During lunch, several elders recounted stories from their lives, gently conveying the life lessons these stories contained.

Many in the United States use a different word to describe older residents: elderly. Although the difference is subtle, elderly is often used in association with a sense of responsibility to provide care, food, shelter, and entertainment. There is less of a sense respect for the wisdom of their life experiences, more of a sense that interacting with the elderly is necessary from time to time. This is a barrier to older adults feeling a sense of purpose as they age. Dr. Victoria Sweet’s excellent book, “God’s Hotel,” about San Francisco’s Laguna Honda Hospital elaborates on the evolution of modern American society’s conceptualization of our older residents.

Of course, there are exceptions to this. In his famous study of communities around the world where substantial populations live to over age 100, author Dan Buettner found that, in addition to a healthy diet, regular exercise, and six other factors, centenarians had an ongoing sense of purpose for their lives, usually including providing advice and support to the younger members of their families. The term “Blue Zones” is used to describe such communities in the Nuoro province of the Mediterranean island of Sardinia, the Nicoya Peninsula of Costa Rica, and Loma Linda, California.

In our early lives, our brains are wired for “fluid intelligence”: the ability to reason and think abstractly and flexibly. This allows us to learn everything from kinesthetic skills like sports or playing a musical instrument to mental reasoning skills involving creative solutions to mathematical or logical problems. As we age, the integration of what we have learned in our lifetimes — from books, other people and from our own experiences — can be manifested in “crystalized intelligence,” sometimes known as accumulated wisdom. Fluid intelligence generally peaks in our 20s and 30s and then declines steadily, whereas crystalized intelligence peaks in our later decades of life. Crystalized intelligence is helpful for teachers, with history professors actually reaching peak intellectual productivity in their 60s and 70s. Interestingly, our ability to learn new words and even new languages can persist well into our older years because the hippocampus, the seat of memory, continues to grow throughout life.

In his book, “From Strength to Strength: Finding Success, Happiness, and Deep Purpose in the Second Half of Life,” economics professor Arthur C. Brooks notes that high-achieving younger professionals who start to decline in their career should intentionally make the jump from the declining fluid intelligence curve to the rising crystalized intelligence curve.

American society celebrates the success of young entrepreneurs, young performing artists, and young scientists who make important breakthrough discoveries that require fluid intelligence. Success in early life, with its attendant public recognition, can make it hard to give it up to make the jump to the second, crystallized intelligence curve. Interestingly, societal belief systems that emphasize the idea that deceased ancestors support those who are living sometimes have more formal ways of recognizing the development of wisdom as a high goal in the second half of life. Confucian stages of life include the ideas of early education, social engagement with accumulation of wisdom in the middle of life, and tapping into the wisdom of elders, sages, and ancestors. As noted earlier, writings summarizing historic and current-day Tribal community values and beliefs include respect for the wisdom of the elders, and the important influence of one’s ancestors on those living today.

A more codified version of these stages is found in the ancient Hindu theory of Ashrama. Ashrama specifies that life should be lived in four stages, each lasting roughly 25 years:

• The first, in childhood and young adulthood, is devoted to learning.
• In the second phase, one focuses on working to build a career and financial stability, as well as to building a family and social connections.
• In the third phase, one retires from personal and professional duties to consolidate their wisdom through teaching and spiritual practices. Moving from the second phase to the third phase is analogous to the shift from the fluid intelligence curve to the crystallized intelligence curve, noted above.
• The fourth phase (if one lives long enough!) is devoted exclusively to spiritual understanding.

Clinician Wisdom

What are the implications of this framework to clinicians?

The scientific framework of evidence-based practice, where activities are tested objectively and rigorously, is at odds with a framework that draws on “ancient wisdom.” In fact, the current standard of care is evolving rapidly. The half-life of medical best practice is roughly five years. Put another way, half of today’s best practices for a given disease condition (e.g., which medication or surgical treatment is the safest and most effective) will no longer be the best practice in five years.

New graduates of physician residency programs, better trained than previous generations in evidence-based practice, will view some of the practices of older physicians as out-of-date. In some ways, though, the skills and experiences of older clinicians integrate knowledge that is not out of date and which younger clinicians would benefit from. Physical exam skills, for example, are becoming a bit of a lost art, resulting in over-use of radiology studies. Surgical skills for non-laparoscopic surgery of older physicians are often impressive, as they had a large volume of such cases before the newer surgical methods became available. Conversely, younger surgeons often have more robust experience with robotic surgery.

Clinicians need to track the evidence base for the conditions they commonly treat. Having a sense of curiosity and skepticism when reviewing the medical literature is key to critically evaluating new knowledge. As clinicians age, the wisdom reflected in their clinical judgement can continue to grow, if they systematically keep up with new knowledge.

Leadership Wisdom

This is also true for clinician leaders, although the nature of new knowledge related to leadership is very different.

Our understanding of the psychological and sociological aspects of human behavior is more scientific than previously, both through more advanced social science research methods, and with greater understanding of how this relates to underlying brain structure and function. The book, “Behave: The Biology of Humans at our Best and Worst,” by Robert Sapolsky is an impressive integration of these fields.

However, clinician leaders generally learn new leadership lessons more slowly, since we are often spending time maintaining our clinical knowledge while concurrently learning business operations and health care policy.

Fortunately, some core leadership wisdom is timeless, and so can be gained through literature, movies, and reading philosophy. An additional vital resource is the crystallized intelligence of our “medical elders,” experienced clinician leaders, such as Dr. Paul Farmer, Dr. Fitzhugh Mullen, and Dr. Anthony Fauci, as well as local clinical leaders in your communities.

To grow and age wisely as clinician leaders, we must embrace the opportunity to absorb the wisdom of elders even while we systematically strive to integrate new evidence-based knowledge!

By Robert L. Moore, MD, MPH, MPA, Chief Medical Officer

“The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.”

– Author Malcom Gladwell

Malcolm Gladwell’s first book, The Tipping Point: How Little Things Can Make a Big Difference, published in 2000, was one of the earliest popular books in the field now called behavioral economics. Classics that followed include Freakonomics, written by Steven Levitt and Stephen Dubner in 2005, Predictably Irrational, by Dan Ariely in 2008, Nudge by Nobel Laureate Richard Thaler and Cass Sunstein, and Thinking Fast and Slow, written by Nobel Laureate Daniel Kahneman in 2011. Collectively, these books combine elegant psychological experiments and data analysis using novel economic methods to dispel age-old assumptions about motivation and human behavior.

In his just-released eighth book, Revenge of the Tipping Point, Malcolm Gladwell examines the factors leading individuals to dramatically change their beliefs and values in response to the people around them. The many healthcare examples alone make it a worthwhile read for Medical Directors.

A particularly thought-provoking chapter is Chapter 4, The Magic Third. He presents a series of studies that show that 25-33% of a group of people can sway the rest of the group to the same set of beliefs/behaviors/values – the “Magic Third.” Examples include studies of the number of women on corporate boards, the number of Black children in mixed-race kindergarten classes, the percentage of Black residents in a neighborhood, and an elegant psychological experiment involving groups of people agreeing on names of random people in images. The “tipping point” in which major changes in the group cascaded rapidly was between 25 and 33 percent of the group. Gladwell goes as far as calling the Magic Third a “Universal Law,” a term social scientists and philosophers use in a way that is disconcerting to physicists.

One interesting experimental finding is that if 25-30% of a group are coordinated in trying to sway an entire group to their view (say on length of two lines, or the number of objects in a picture), they will generally be successful, even if the view they are agreeing on is demonstrably untrue! Social pressure is powerful!

On the other hand, the current political environment in Washington D.C. demonstrates that deeply held beliefs are not as susceptible to the “Universal Law” of the Magic Third.

I have observed cases where less than one third of a group can sway the entire group. In the 1980s, vintners in different areas of California formed local trade groups to promote wines from their region. They sometimes held charity fundraisers, combining marketing of their products with philanthropy. In one case, the Napa Valley Vintners, the target of fundraising shifted substantially from supporting local hospitals to focus on supporting the farmworkers and their families who worked in the region. This change occurred when just two board members (former publisher John Shafer, owner of Shafer Vineyards, and Bill and Kathy Collins of Conn Creek Winery) worked together to sway the views of their fellow vintners. For approximately 30 years (even after the deaths of Shafer and the Collins’s), vintners throughout the valley would all say that the focus of their wine auction and other philanthropic activities was to care for the farmworkers who worked in the fields, making their wine possible. Vintner groups in surrounding counties did not develop the same shared goal.

A key lesson from the Napa Valley Vintners is that two charismatic leaders, working together, can shift the views of an entire group, even if they initially comprised less than 25% of the group. However, it takes a bit of effort and time to get to the tipping point and beyond.

A look at major public health initiatives in California and other major health policies find this pattern repeating: two passionate dedicated individuals focus their energy to changing the framing or narrative, gradually swaying the larger group (or even the whole population) to their frame/narrative.

If one person has an innovative policy idea, their first important task is to find a second charismatic person who will support the idea. Together, with time and attention, these two can often sway the rest of the group.

Patience and focus are key. Having too many priorities means that insufficient attention goes to any one of them, and success will be limited. Partnership HealthPlan of California tracks the public health priorities of all 24 of our counties. In some counties, there are so many priorities that the health officer cannot remember them all without looking them up. Lake County has adopted a different model inspired by a framework called Collective Impact. The health department is mobilizing all major county stakeholders to focus intensively on one high priority issue: nicotine consumption in youth. I have no doubt that this approach will have a substantial impact.

So, don’t make too many New Year’s Resolutions. Choose no more than one difficult-to-achieve goal and stick with it. If your goal requires changing the behavior or views of people around you, first find a partner to work with you.

As we look ahead to 2025, which may bring many changes, finding ways to make meaningful differences in our communities can provide resilience. We at Partnership look forward to working with you to make our local healthcare system as functional as we can, providing care and comfort to the communities we serve.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

 “I am often reminded of the adage, ‘If you are not at the table, then you could be on the menu.’ If I am not getting out and having my voice heard by those who make decisions, I am not doing my job.”

– Pat Rusk, elementary school teacher and former president of the Utah Education Association

In an energetic meeting marked by some controversy, California physicians debated priorities for supporting health care in rural parts of California and ensuring access to safe obstetrical services at the California Medical Association (CMA) House of Delegates (HOD) meeting in Sacramento, October 26-27, 2024.

CMA membership is dominated by physicians working in urban and large suburban areas, especially those working at large medical groups such as Kaiser and Sutter. Although the two issues under discussion were especially important for rural clinicians most CMA members expressed support for their colleagues who have chosen to practice in rural settings.

For rural health, 14 recommendations were adopted by the HOD, including:

• Supporting public health-funding allocation models to ensure adequate funding for small rural counties.
• Calling on congress to increase the number of visa waiver slots available in California for physicians practicing in rural areas.
• Calling on Department of Health Care Services (DHCS) to remedy the systematic undercounting of American Indians in Medi-Cal data.

One area of controversy was a proposal to create a Section of Rural Physicians with influence at the Board of Trustees level. The executive leadership and governance committees agreed to take up this topic at a future meeting.

To kick off the OB access topic, Surgeon General (OB/GYN) Dr. Diana Ramos presented up-to-date data on serious maternal morbidity and mortality in California and unveiled her pre-conception screening program, “Strong Start & Beyond.”

For obstetrical services, 18 recommendations were adopted by the HOD, including:

• Support for funding low volume hospitals using mechanisms such as standby capacity payments.
• Alignment with increasing the support for training clinician workforce to provide obstetrical care, including perinatal case managers.

The role of family physicians (FP) that are trained to provide operative obstetrical services in rural areas generated some controversy, with urban/academic OB/GYNs expressing skepticism that FP[1]OBs can provide safe care in rural areas, while family physicians working in rural areas spoke up to defend their role in providing rural obstetrical care. This is not a settled issue; continued advocacy is needed to educate urban OB/GYNs on how OB care is provided in rural areas.

The other important action of the HOD was that in a tight, three-way race, pediatrician Dr. Rene Bravo of San Luis Obispo won the election for president-elect. He presented an excellent understanding of rural issues and primary care; representatives from district X and XI were pleased with his election.

Many physicians from Partnership’s 24 counties enthusiastically participated in the activities, including seven Partnership medical directors. County medical societies in CMA districts X and XI represent 23 of Partnership’s counties (Marin is served by district VIII). These districts were especially active in presenting amendments and debating the proposals.

The medical directors at Partnership strongly encourage all physicians in our service area to join the CMA and their local medical society to ensure representation and a voice in CMA policy decisions. Ideally, the organizations hiring these physicians would support the membership dues because physician advocacy complements other mechanisms for influencing health policy in Sacramento, such as trade organizations and specialty organizations.

In addition to being a member of your local medical society, if you have interest in influencing health policy, the first step is to attend the county medical society events and executive committee meetings, volunteering to be a delegate or alternate delegate for the HOD.

The next HOD meeting will be on October 18-19, 2025, in downtown Los Angeles. If you want to learn more about how to influence our health care delivery system and support policies that support the health care system in rural California, we encourage you to consider attending!