Innovation
Toxic Stress Network Improvement Collaborative (TONIC)
Bay Area
Description
The Toxic Stress Network Improvement Collaborative (TONIC) brings together cross-sector leaders to transform care systems so young children and their families can thrive.
TONIC is guided and held accountable by its Family Accountability Board (FAB), a group of caregivers with knowledge of the Medi-Cal benefits that provide supportive factors for care coordination and the social determinants of health for families.
Currently, the focus is on supporting the local implementation of two state Medicaid benefits: Dyadic Care Services and Cal-AIM’s Enhanced Care Management (ECM). TONIC members successfully advocated to make dyadic care (an approach to healthcare that focuses on the relationship between the child and caregiver as a key factor in the child’s health, development, and behavioral well-being) a reimbursable Medi-Cal benefit. TONIC also supports the integration of lived experience in the implementation of the dyadic benefit via the University of California, San Francisco (UCSF) Center for Advancing Dyadic Care in Pediatrics. This collaboration has resulted in the co-development of dyadic care tools with families that providers and clinic systems may use. TONIC is also piloting and creating resources around ECM and other case management benefits to support young children and their families who are exiting the child welfare system, ideally preventing re-entry into the system.
Need / Problem Statement
“Why do traumatic things have to happen in order to get support?” – FAB member
Too often this is the reality for young children and their families in the Bay Area. TONIC is on a mission to change that and is transforming systems of care to support preventative strategies and programs that families can easily understand and utilize.
Process
TONIC creates a collaborative space for early childhood leaders to openly address challenges and solve real problems in delivering quality care.
The team pilots innovative care management programs to help make sense of complicated state Medi-Cal policies and make the case for county-level implementation. TONIC and the TONIC FAB have co-produced policy papers, resources and toolkits, and disseminated learnings to support San Francisco and other counties to transform their system of care to better support young children and families. The FAB collaborates with TONIC to ensure that programs and resources truly meet the needs of families. The FAB partners with TONIC to ensure the direction and products are what families need. One example is the recently launched Child Welfare Family Maintenance Status pilot in response to parents who asked why supportive resources are not offered earlier.
Resources include the following FAB-driven toolkit, webinar, and papers informing statewide organizations and public agencies:
- Toolkit and webinar on Consent and Information Sharing
- Papers:
Child Welfare-Involved Children and Families in San Francisco
Understanding a Unique Population: Families with Children Aged 0–5 in a Family Maintenance Placement
TONIC’s collaboration with the FAB represents a continuous cycle of learning, listening, and implementation, ensuring that policy and clinical innovations are truly driven by families’ lived expertise.
Partnership
Key partners include community based organizations, managed care plans (San Francisco Health Plan and Anthem Blue Cross), San Francisco Department of Public Health, San Francisco Human Services Agency, San Francisco Department of Early Childhood, San Francisco Family and Children’s Services, University of California, San Francisco, Zuckerberg San Francisco General Hospital, UCSF Center for Advancing Dyadic Care in Pediatrics, Public Works Alliance, funders, and family leaders experienced in Medi-Cal and child welfare systems.
Implementation
TONIC launched in 2019 on the premise that clinical innovations, such as dyadic care, will optimize impact and sustainability if they are grounded in cross-sector collaboration and not done in isolation.
As UCSF faculty began the dyadic care pilot in the County’s Children’s Health Center, they engaged managed care Medi-Cal health plans, community organizations, local government agencies, and clinicians with a focus on young children and their families in SF County. Together, the team identified opportunities and strategies to improve the care of young children. This included strategies such as data sharing, systems, patient journey mapping, and engaging lived expertise. In 2022, the team formally launched the FAB. Implementation required iterative processes including re-examining infrastructure, partnership building, iterations of goals and workplans, and developing creative financial mechanisms for timely and unburdensome FAB payments. TONIC developed an action-oriented working group and engaged its larger network in quarterly updates. Together, TONIC has established a long-term vision for a family-driven approach for early childhood systems as the new standard of practice, one that is impactful, valued, and sustained.
Changes & Outcomes
TONIC has seen their model create lasting change for families in the Bay Area.
TONIC’s innovations demonstrate multiple improvements in family engagement and systems collaboration, including:
A dyadic care pilot that was successfully implemented at Zuckerberg San Francisco General Hospital and later adopted as a statewide Medicaid benefit– closing a gap in access to care that has the potential to improve the well-being of over 5 million young children and young adults on Medicaid and their families across California
A child welfare pilot project that is currently being implemented to assess whether case management benefits can reduce Child Protective Services (CPS) re-entry rates
FAB recommendations and leadership that have shaped systems change resources and tools used across the State of California
Data-sharing agreements and cross-sector partnerships to strengthen the countywide capacity to coordinate care for children ages 0–5
Measurement for Success
TONIC is co-designing an evaluation plan to formalize metrics for success that include:
- Uptake of Medicaid care management benefits (dyadic services and ECM)
- Reductions in child welfare involvement
- Dissemination impact of family-developed tools
Long-term, this site anticipates that the utilization of established Medicaid benefits at the start of life creates cost savings across health care, public health, and social service agencies by preventing long-term chronic disease and emergency room use while improving family well-being and reducing long-term health expenditures. Foundations and aligned partners have sustained TONIC and provided compensation for FAB activities.
Payment & Funding
- Funding type: Philanthropic support (foundations and aligned partners) has sustained TONIC and the Family Accountability Board.
- Anticipated gains: Prevention of re-entry into child welfare systems creates cost savings across public health and social service agencies, while improving family well-being and reducing long-term health expenditures.
To learn more about this innovation please email Charlene Choi, Principal Policy Analyst at UCSF/Safe & Sound: [email protected].
