Palo Alto Medical Foundation

Respiratory Care Clinics: How Dedicated Exam Spaces Limit the Spread of Viruses

Posted on May 26, 2020 in Carousel, Expanding Access, Innovation, Palo Alto Medical Foundation, Quality, Safety, Scroll Images, Uncategorized

BAY AREA, Calif. – Its second nature for people to visit their doctor’s office or an urgent care center when they’re sick — or are worried they might be. In early March doctors across the Sutter Bay Medical Foundation prepared for patient demand at these locations by developing Respiratory Care Clinics (RCCs); an outdoor exam experience that keeps potentially contagious people distanced from those that aren’t, while allowing all who need in-person care to receive it.

“We always knew patients would have concerns that were serious enough to need an in-person exam, but not urgent enough for a trip to the emergency room,” said Kurt Vandevort, M.D., inter-regional medical director for the Palo Alto Foundation Medical Group, part of the Sutter Medical Network. “As community-based providers this middle level of care is what we do best, so it was incumbent on us to find a way to keep providing it, safely.”

By March 16th the Sutter Bay Medical Foundation had established fifteen RCCs in cities across the Bay Area, each seeing patients with COVID-19 concerning symptoms (or who reported a potential exposure to the coronavirus), outside of a nearby medical building that needed to stay open and clean for patients with urgent or medically necessary needs unrelated to COVID.

A month into their operation reporters from The Mercury News and San Francisco Chronicle took notice and wrote about these MASH-like clinics. Now, as Sutter Health resumes more routine patient visits, the RCCs will continue to separate patients with respiratory symptoms from those without, to reduce the risk of exposure to viruses, including the novel coronavirus. Read below to learn more about how the RCCs work and what to expect if you are directed to one.

Call First 

Sutter Health is focused on helping ensure patients have access to the right level of care to match their medical need, but we also understand that sometimes that’s hard for people to gauge. That’s why Sutter Health set up the COVID-19 Advice Line at 1-866-961-2889.

Staffed by a team of nurses from 8 a.m. – 6 p.m., seven days a week, every caller is screened for symptoms linked to coronavirus. Callers are then directed to the most appropriate level of care based on the severity of their symptoms. Patients may be directed to self-monitor at home, to see a provider by video visit or to come to an RCC location where they can receive an in-person exam.

“By linking the RCCs to a pre-screening process (by phone or after a video visit) we can ensure patients coming to RCC do need to be seen in-person, and aren’t ill enough to go straight to the emergency room,” said Dr. Vandevort, who is also the medical director of the RCCs established throughout the Palo Alto Medical Foundation footprint. “When patients arrive at the RCC we also have some information about their chief concerns, thanks to notes entered in our electronic medical record.”

Different, by design 

A physical exam in a parking lot or garage is strange, but the safety that these setting offer is worth the weird-factor. “To protect patients, staff and the community we designed the RCCs to first and fore-most prevent transmission of any virus from a contagious person; that’s why most of them are outdoors and anyone who comes within six feet of the patient is in full personal protective equipment” said Dr. Vandevort. “At the same time we took great pains to try to make the experience similar to what patients are used to when they go to the doctor or urgent care.”

The outdoor RCCs all have a contact-free arrival process, allowing patients to drive-up and call a phone number to “check-in” for their appointment. At every stage of the visit the patient is distanced from others by either staying in their car or in a marked off space within an exam bay.

In addition to an initial temperature check, patients will have their lungs listened to with a stethoscope, have their blood oxygen saturation checked, have their medical history and medications reviewed, and may be tested for coronavirus or the flu if symptoms indicate they should be. Depending on medical need, patients will also receive additional tests and procedures, including imaging scans, blood draws, heart monitoring and more.

The few indoor RCCs are all in buildings, or sections of buildings, that can safely be separated from other areas where patients who don’t have respiratory symptoms are being seen. The indoor RCCs have implemented all the necessary transmission precautions to ensure that spread of a virus from patient to patient or patient to staff is prevented.

Not Just COVID Care

In addition to screening and treating respiratory complaints, the RCCs have filled another important role; addressing non-respiratory related issues reported by patients who have symptoms linked to COVID (fever, cough, shortness of breath). “Just because COVID-19 is here, that doesn’t mean that other illnesses and injuries go away,” said Dr. Vandevort. “One of the best things about the RCCs is that you are being evaluated by a physician who can treat a wide variety of minor illnesses or injuries, prescribe medications or make a dosage change to an existing medication, and otherwise address a whole host of concerns. It’s what we do every day, and in these safe settings, we can keep doing our job even for patients who may have a virus and be contagious.”

In the short time the RCCs have been up and running, doctors staffing them have made unexpectedly important diagnoses and delivered increasingly complex care. “We’ve seen and treated conditions ranging from an appendicitis, to a swallowed fish bone, to an infection requiring IV antibiotics. We’ve done a lot of good.”

Twice the Team 

It’s not easy to run two clinics (one regular and one RCC), simultaneously, just feet apart, but for the safety of our patients and providers that is what we’ve done. “We had to reassign doctors and nurses so we had coverage in both the RCC and the regular urgent care at the same time, some staff now act as a front-door attendants making sure that patients are directed to the right clinic based on their symptoms, and others are runners shuttling supplies between the two spaces.”

All this investment was made for one reason: to prevent the spread of illness. But the RCCs have had several secondary benefits too.

“We’re also helping to preserve hospital capacity by keeping patients from going to the emergency department unnecessarily.” You wouldn’t normally go to the ER for a fever, and the RCCs make sure our smart use of resources stays intact, even during a pandemic.

At the same time, the RCCs have helped refer patients to a higher level of care when that was needed. “Our job is to help stabilize people so they can safely return home, but when their symptoms are serious we help get them to the hospital.”

Data Detectives Track the Pandemic

Posted on May 13, 2020 in California Pacific Medical Center, Expanding Access, Innovation, Palo Alto Medical Foundation, Quality, Research, Scroll Images, Transformation

Like a shadow lengthening at sunset or a dark cloud slowly obscuring the sun, the novel coronavirus has the potential to spread silently before positive tests confirm diagnoses in people infected with the virus.

To help get ahead of the curve and prepare Sutter’s integrated healthcare system to manage a potential surge in infections or a re-emergence of novel coronavirus later this year, Sutter leaders are collaborating with researchers and statistical analysts to track infection rates in the Sutter patient population and predict the course of viral spread.

Sutter researchers are experts in data analysis who leverage current and new methods aligned with Sutter privacy safeguards. Their work helps strengthen Sutter’s response to the pandemic. Here’s how:

1. TRACK THE VIRUS: Sutter Health Biobank
Sutter researchers are exploring ways to detect the novel coronavirus before it spreads further, by assessing exposure rates in Sutter’s patient population. This effort is led by Gregory Tranah, Ph.D., Scientific Director of CPMC and Director of Sutter’s Center for Precision Medicine Research.

The COVID-19 Seroprevalence and Surveillance Study will identify blood and serum samples from Sutter Biobank volunteer participants that show antibodies against the novel coronavirus. “Seroprevalence” means the level of a virus or other pathogen in a population, as measured in blood.

“Understanding the surge of infection rate and spread is an important part of preparedness. Epidemiological studies of emerging COVID-19 infections can help determine the burden of disease, develop better estimates of morbidity and mortality, and guide return-to-work and personal-safety decisions based on exposure history,” says Dr. Tranah.

The Sutter Biobank has been enrolling patient volunteers to give blood samples when a blood draw is ordered for clinical reasons. From early December 2019 through March 21, 2020 over 700 Biobank participants had blood samples drawn and archived.

“These samples provide Sutter with a unique opportunity to perform population-based surveillance of COVID-19 exposure when the virus began to spread in Northern California. They represent highly diverse patient data from Sutter’s integrated network. This is meaningful information that will allow us to determine the rate and timing of peak exposure and leveling of exposure rate,” says Dr. Tranah.

“Further, we can use the Biobank samples to find potential evidence of a resurgence of COVID-19 infection this fall. Earlier detection means we can plan for early containment of the virus.”

2. MONITOR VIRAL SPREAD: COVID-19 Surveillance
Researchers and statistical analysts at Sutter’s Center for Health Systems Research (CHSR) are collaborating with Sutter’s Enterprise Data Management, Informatics, Information Services and other operational departments to perform much-needed surveillance on the COVID-19 pandemic and provide insights to Sutter leaders.

Each morning, the CHSR team prepares reports for all Sutter hospitals on the number of patients who have tested positive or are suspected of being positive for COVID-19. They also track total hospital capacity and intensive care unit bed occupancy to help front-line staff with surge-capacity planning.

“Surveillance helps us understand how COVID-19 may be spreading amongst the patients we care for and our healthcare workers, and how we can prepare for potential surges in viral infection rates in the coming months,” says Alice Pressman, Ph.D., MS, Co-Director of CHSR.

Dr. Pressman and her colleagues at CHSR are developing the COVID-19 Universal Registry for Vital Evaluations (CURVE)—a centralized resource for research and quality improvement activities for COVID-19 disease surveillance and modeling, as well as health services and epidemiologic analyses.

“The registry will allow us to conduct research to assess the impact of COVID-19 on the healthcare system, Sutter patients, and our community of employees and healthcare workers,” says Dr. Pressman.

This registry develops the structure for the minimum necessary data to be used for each project, securely within the Sutter network. In turn, the knowledge gained can help to inform patient care and operations as Sutter continues to face COVID-19.

In support of Sutter’s Advancing Health Equity initiative, the CHSR team studied the demographics and clinical characteristics of COVID-19-infected individuals and their outcomes, which helped identify patient subgroups that may be more vulnerable to the disease. Early results indicate there may be inequities by sex, race, ethnicity and socioeconomic status.

“Research during a pandemic is vital to determine which parts of our communities and sub-groups of patients are most affected, so that we can allocate resources and care for our most vulnerable patients,” says Dr. Pressman.

3. A MATHEMATICAL CRYSTAL BALL: Statistical modelling to help predict the future of viral spread
One of the challenges of the COVID-19 pandemic is that scientists don’t fully understand the impact of the virus or its prevalence in our communities.

“One way to help answer these questions is through statistical modeling,” says Dr. Pressman. “We can use infectious-disease models as tools to help us predict the future of the novel coronavirus spread and the potential impact of social distancing and containment efforts on flattening the curve.”

Dr. Pressman and her team are collaborating with researchers from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington to understand the models IHME has published for California state COVID-19 data. “We hope to apply these models to our system to help us allocate healthcare resources and make decisions about future containment efforts.”

Data crunching to help halt a pandemic:
Surveillance is the systematic collection, analysis and interpretation of health-related data. For surveillance of the novel coronavirus and COVID-19, Sutter is using surveillance systems to monitor COVID-19 disease across the system. Surveillance and biobanking can help:
• Monitor the spread and intensity of COVID-19 disease
• Understand disease severity and the spectrum of illness
• Understand risk factors for severe disease and transmission
• Monitor for changes in the virus that causes COVID-19
• Estimate disease burden
• Produce data for forecasting COVID-19 spread and impact
• Improve patient care and help improve Sutter’s response to the pandemic

Coronavirus Science: Two Studies Raise New Concerns

Posted on May 5, 2020 in Carousel, Innovation, Mills-Peninsula Health Services, Palo Alto Medical Foundation, Pediatric Care, People, Research, Scroll Images, Uncategorized

Every day brings new scientific insights into COVID-19 and the coronavirus that causes it. Studies authored by Sutter Health experts examine the virus’s impact on children and diabetic adults.

COVID-19 and Kawasaki Disease

Recently, doctors began warning of a potential consequence of COVID-19 infection in children; some youngsters appear to develop an abnormal immune response that results in symptoms commonly associated with Kawasaki disease or toxic shock syndrome – two rare, but well-characterized inflammatory conditions. The first known U.S. case of Kawasaki disease possibly connected to COVID-19 was reported by Veena Jones, M.D., (lead author) and Dominique Suarez, M.D., both pediatric hospitalists with the Palo Alto Medical Foundation, part of the Sutter Medical Network.

Veena Jones, M.D.

Their six-month-old patient was diagnosed with classic Kawasaki disease, admitted to the hospital for treatment, and subsequently received a positive test result for COVID-19. The main reason for treatment in children with Kawasaki disease is to prevent further complications of the disease on the heart. The patient received appropriate treatment and has since fully recovered and has maintained normal heart function. But the case caused the doctors to question: could the COVID-19 infection have led the patient to develop Kawasaki disease?

“Our patient met the classic criteria for Kawasaki disease, so there was little doubt about the diagnosis or treatment plan,” said Dr. Jones. “But we do wonder if the COVID-19 infection could have caused the Kawasaki disease, especially because Kawasaki disease is widely thought to be triggered by an infection or an abnormal immune response to an infection.”

Dominique Suarez, M.D.

A careful review of the existing medical literature found that COVID-19 co-occurring with Kawasaki disease had not previously been reported, so the doctors decided to write up the case and submit it to the Journal of Hospital Pediatrics for publication. “Researchers still know very little about exactly why Kawasaki disease develops in some patients, so our hope was to accurately describe the novel case that we encountered and share that with the medical community to encourage further investigation and dialogue,” said Jones. In the race to understand the burden of COVID-19 on the human body this kind of early observation by doctors on the frontline can help inform future decisions around diagnosis and treatment.

COVID-19 and Diabetes

Since the start of the coronavirus pandemic many have warned that people with existing chronic illness who contracted the infection would become sicker than those without. Now, research authored by Sutter Health clinician David Klonoff, M.D. suggests that diabetes, one of the most serious chronic illnesses in the world, is strongly correlated with death among hospitalized patients diagnosed with COVID-19.

David Klonoff, M.D.

Accepted by the Journal of Diabetes Science and Technology, Dr. Klonoff’s paper represents the largest study yet reported on outcomes of patients with COVID-19 and diabetes or uncontrolled hyperglycemia. The observational study of 1122 inpatients with COVID-19 at US hospitals between March 1 and April 6, 2020, found that those with diabetes or hyperglycemia throughout their hospital stay had a four-fold greater inpatient mortality than those without diabetes or hyperglycemia. In a further subset analysis, death rates were seven-fold greater among those who did not have evidence of diabetes prior to admission, but developed hyperglycemia during their hospitalization.

The study also demonstrated that during a hospitalization for COVID-19, the presence of diabetes or hyperglycemia was associated with a longer hospital stay and slightly worse kidney function.

“I am now analyzing the same database to determine whether COVID-19 patients with diabetes and uncontrolled hyperglycemia, who were better controlled in the hospital, had better outcomes,” said Klonoff. If an association between greater survival and achieving target glycemia (following initial hyperglycemia) is demonstrated, and acted on, lives could be saved.

“These data may have wide implications for how we care for COVID-19 positive patients who experience hyperglycemia during their hospital stay or who have already been diagnosed with diabetes.”

The Digital Doctor Is In: Healthcare Services You Can Access at Home

Posted on Apr 17, 2020 in Carousel, Innovation, Palo Alto Medical Foundation, Scroll Images, Uncategorized, We're Awesome

SACRAMENTO, Calif. – Receiving sound medical advice is more important now than it’s ever been. Albert Chan, M.D., chief of digital patient experience at Sutter Health, shares how you can get advice and take action, all from your living room.

Dr. Chan answers questions from Sutter Health staff in the Q&A below.

Search Your Symptoms

Q: Google has reported a surge in searches related to COVID-19. Are search engines able to give results that can help real people get the counseling and care that they need right now?

Albert Chan, M.D., Sutter Health’s
chief of digital patient experience

A: Many people who develop a fever, shortness of breath, or cough right now may be concerned that they have COVID-19. While Google, WebMD and other online tools are good at providing general guidance, they can’t suggest concrete care options, because they aren’t connected to a group of medical providers.

Sutter Health’s online Symptom Checker is a little different. After entering your brief medical history and current symptoms, you will receive a personalized health assessment and can then enter your location to find nearby care options offered by the Sutter Health network.

Originally launched in February 2019, I see the Symptom Checker as a way to help patients decide whether to engage in self-care or to seek care, if they need an in-person appointment or a video visit, and if they need to be seen now or soon. These distinctions are incredibly apt as we face the COVID-19 outbreak, concurrent with flu and allergy seasons. I’m proud that the Symptom Checker has been updated to recognize a possible COVID-19 infection, and guide patients appropriately.

Turn to the Telephone

Q: Having a trusted source of information and the ability to talk through your symptoms is desperately needed right now — what is available to the public?

A: The public has a few options, one of which is the Sutter Health COVID-19 Advice Line at 1-866-961-2889.

Staffed by a team of nurses from 8 a.m. – 6 p.m., seven days a week, every caller is screened for symptoms linked to coronavirus. Callers are then directed to the most appropriate level of care, including self-care at home for those with mild symptoms.

Please note: The COVID-19 Advice Line is intended for people who are ill or caring for someone who is ill. For general information about coronavirus, please refer to the Centers for Disease Control and Prevention (CDC) website. The COVID-19 Advice Line is not for emergency situations. If you think you are experiencing a medical emergency, please call 911 or visit the nearest emergency room.

Seeing is Believing

Q: Some things are hard to diagnose or make decisions about over the phone, what other options are available for patients?

A: Patients can get virtual care from their phone, tablet or computer through Sutter Video Visits. This video gives you a sense of the video visit experience.

We offer a couple of options:

Video visits are expanding to address many primary and specialty care needs. Patients can now call or message their care team via My Health Online to check the availability of video visit appointments with their clinicians.

If you have not yet enrolled in My Health Online, you can now sign up online.

We also offer same-day video visits with our Sutter Walk-In Care clinicians daily from 8 AM to 8 PM for common health issues. Patients can self-schedule a video visit appointment by logging into My Health Online or calling (800) 972-5547 for same-day appointments.

Currently we are conducting virtual assessment of respiratory symptoms daily, which provides both convenient access to care to patients at home and minimizes the risk of spreading illness to others. These video visits can also provide clinicians with the information necessary to decide if a patient ultimately needs to be seen in person at one of our clinics or the hospital.

For more information about COVID-19, please visit Sutter Health’s resources page.

In Need of a Break: Art in Action

Posted on Apr 15, 2020 in Carousel, Palo Alto Medical Foundation, People, Scroll Images, Sutter Maternity and Surgery Center, Santa Cruz, Uncategorized, We're Awesome, Year of the Nurse

SANTA Cruz, CalifTawnya Gilbert, R.N., C.C.R.N. is normally the picture of positivity: upbeat and energetic. But one day in late March, after a shift and a week that all felt especially long and challenging, she felt down. Like all of us Gilbert was concerned about the spread of coronavirus, but unlike most of us, she faced the challenge daily, working as a nurse for Sutter in Santa Cruz County.

“It’s moments like that when I usually go to our staff breakroom and just take a minute to get back in touch with myself, my heart,” said Gilbert, who is also a yoga instructor. “I can usually use the quiet room to recharge and clear my head, but this time was different.”

That’s when she had an idea

“I looked around – at the magazines, the picture window, our little bulletin board – and realized that there wasn’t any art.” Though not an artist herself, Gilbert has always admired the generous amount of art on the walls of Sutter Maternity and Surgery Center. She even helped choose the art in the hospital’s post-anesthesia care unit where she has worked for the past six years.

“I just knew that if we could get some art in the breakroom, and especially if it depicted how healthcare workers are fighting this pandemic, it would inspire staff and lift their spirits.”

The “Surviving COVID” art project began

Gilbert wrote to all the artists she knew, and several she was introduced to, and asked for art that was funny, profound, or uplifting. She encouraged themes of beating coronavirus and thanking healthcare workers, and soon she had 14 original pieces to display in the breakroom at the hospital. The art was an instant hit with staff, and the project has since spread to the Palo Alto Medical Foundation (PAMF) medical buildings in Watsonville and Santa Cruz, the emergency room of neighboring Dominican Hospital and the halls of nearby Watsonville Community Hospital.

Babs Kingsley, M.A., R.N., manager of emergency services at Dominican Hospital said “the staff are incredibly grateful for the donated artwork and sentiment from the community that it represents. The art is providing staff with motivation and strength, and the collaboration between healthcare networks reminds us that we are not fighting this battle alone. Many thanks to Tawnya for helping us turn an uncertain time into one of collaboration and pride.”

Art is an antidote to fear

“Art comforts and connects us; when a doctor, nurse or housekeeper views these images I hope they see an entire community of artists who are supporting them and helping them process emotions that are hard to put into words,” said Gilbert.

Creativity and positivity abound in the works collected to-date. “Glove Conquers All,” for example, is a take on the raised fist, a symbol of solidarity that is used to express unity and strength. In this original work by Andi Mellon, the fist is encased in a glove and surrounded by Gladiolas which symbolize bravery.

Another piece that features gloves is “Creation” by artist Michael Lane. The work imagines an update of the classic “Creation of Adam” for our modern moment. “With all the precautions required for coronavirus, I thought it would be interesting to add a twist on safety to this iconic piece,” said Lane.

“The Brave Nurse” depicts the importance of sheltering-in-place and the bravery of a nurse who protects her community from COVID-19, represented as attacking balls with sharp teeth and angry eyes. Seamlessly blending literal and figurative references, artist Lily K. has been able to include several key elements of the pandemic in one uplifting scene.

Calling all artists

Little more than a week after her idea-inspiring low point, Gilbert feels energized by the entirely volunteer-led and donation-dependent project.

“Today I worked 10 hours, ate dinner, read to my daughter, spoke to two artists about sharing their art and applied for a grant. I’m going to bed, rest well Santa Cruz,” she wrote to friends and family.

Gilbert has been overwhelmed by the response from the community, in the form of art and framing supplies, and she encourages anyone who wants to help to email her at: lokilove28@gmail.com

A Message For Millennials On COVID-19

Posted on Apr 6, 2020 in Affiliates, Palo Alto Medical Foundation, Scroll Images

My fellow millennials:

Like many of you, I like a good Sunday brunch and avocado toast, I can’t live without Netflix and Amazon Prime, and I scroll through Yelp and Eater much too often in search of that perfect new restaurant. Like many of you, I am a millennial. And yes, my last name is really Bae.

I’m also a doctor and I’ve witnessed multiple epidemics. In 2006, I was in Southern Africa when HIV/AIDS was ravaging the continent; in 2014, I was in Liberia during the Ebola epidemic

Dr. Jason Bae, Palo Alto Medical Foundation
Dr. Jason Bae

1. We millennials are NOT immune to dying from COVID-19. You’ve probably heard that COVID-19 is much more deadly for the elderly than for millennials. That’s absolutely true. Those who are older than 80 have a >10% chance of dying if they were to get COVID-19. That number goes way below to 0.1-0.2%, or approximately 1 in 700, for folks in their 20s and 30s.

I know many of you may be thinking, “That’s such a low chance, so why should I care?”

Although a 1 in 700 chance may seem small, compare that tothe chances of dying from base jumping, one of THE most dangerous sportactivities in the world. It has a 1 in 2,300 chance of dying – which is threetimes less than from COVID-19.

A six-car Caltrain holds about 750 passengers when full. If someone told you, “One person on that train will be chosen to die at random,” would you ride that train?

Here’s more data: nearly 40 percent of people hospitalized with COVID-19 in the U.S. are between the ages of 20-54.

2. There are likely millions — if not tens of millions — of people infected in this country today. I recently talked about how the current number of confirmed cases in the U.S. drastically underestimates how many actual infections are out there. Not only does there continue to be delays in testing and reporting across the country, but a very small fraction of people with symptoms have been tested nationally because of the shortage of testing supplies.

3. This pandemic will be over sooner if we all do our part. According to an article in The New York Times, experts predict more than 200,000 Americans may die from COVID-19 within a year. Most will be elderly, which means many of our children will grow up without their Nanas and Dadas.

Group of millennials

We know that young people contribute significantly to this ongoing spread of this pandemic. We are the most common transmitters of the disease, and many are infectious without experiencing any symptoms.

The longer we wait to be serious about this epidemic, the longerit will be before we can get back to normal life. In the meantime, more peoplewill have died, more businesses will have closed, more employees will be out ofa job, and more damage will be done to our economy. Our very own economicfuture will be uncertain.

I come home from work every day and go straight to a roomwhere I lock myself up. I haven’t hugged my child or wife in days for fear oftransmitting the disease. I go to work knowing there is a significant chance ofcatching COVID-19 and there’s a real chance of dying from it. Despite it all, Igo to work willingly because I didn’t go through all this training to simply siton the sidelines while people are dying.

My fellow millennials, you can help by simply staying home. Practice social distancing. Talk to your parents about the importance of staying home. Talk to your friends who don’t care about why they should.

And remember that this pandemic, like all other pandemics that have come and gone, will end. That day will be here sooner — and with fewer deaths of our loved ones — if we take this pandemic seriously and practice social distancing now.

Thank you,
Dr. Bae

Dr. Jason Bae is as an urgent care physician affiliated with Palo Alto Medical Foundation (PAMF) and Sutter Health’s not-for-profit integrated network of care in Northern California.