Rady Children’s Hospital is Transforming Healthcare in San Diego Through PATH

Rady Children’s Hospital in San Diego is improving health outcomes for children and youth and building a more responsive, resilient health care system for generations to come. The following success stories highlight how Providing Access and Transforming Health funding is empowering the pediatric health care hospital to invest in a skilled workforce, implement Medi-Cal best practices, and scale their programs to reach new communities.  

Creating a Pediatric-Ready, Community-Rooted Workforce Through PATH 

With support from Providing Access and Transforming Health (PATH) Capacity and Infrastructure Transition, Expansion, and Development (CITED) funding, Rady Children’s Hospital is investing in a workforce that prioritizes empathy, expertise, and equity.  
 
Their Enhanced Care Management (ECM) team is more than a care coordination program—it’s a workforce development pipeline grounded in the needs of the community it serves. Housed within the Population Health Department, Rady Children’s Hospital’s ECM program was designed to uplift diverse voices, backgrounds, and skill sets. 
   
Lead Care Managers (LCM) are valued for their clinical or administrative expertise and their cultural and lived experience. Many have backgrounds in Medi-Cal-focused programs, such as the Center for Healthier Communities and Developmental Services. Several are bilingual, reflecting the patients and families they support. Others are former Healthcare Effectiveness Data and Information Set (HEDIS) outreach specialists, bringing population health knowledge to their ECM work. 
   
PATH funding is empowering Rady Children’s Hospital to provide tailored onboarding to team members, including training in motivational interviewing, trauma-informed care, and culturally responsive care planning. The hospital collaborates closely with Rady Children’s Child Life Specialists to adapt care planning for kids, making meaningful family engagement possible. ECM LCMs are also trained to navigate internal referral pathways, such as the CLEAR behavioral health navigation team, and to document and track progress through integrated REDCap and Epic workflows, ensuring coordinated, whole-child support. 
   
By embedding ECM within a renowned pediatric hospital and health network, team members can access mentorship, continuous training, and alignment with broader public health and clinical initiatives. Most importantly, families benefit from a workforce that looks like them, understands their struggles, and can build and sustain trust. 
   
One example is a teenager diagnosed with schizophrenia, grappling with the weight of a serious mental illness and complicated family issues, including a mother involved in the justice system. Struggling to attend school and consistently take their medications, their life seemed to be spiraling out of control. Once they were referred to ECM from outpatient psychiatry, their dedicated LCM connected them to a supportive school environment with academic help and access to behavioral and mental health systems, offering a lifeline to a brighter future. 

This story reflects the heart of Rady Children’s Hospital’s ECM program: a care team that is skilled, reflective of the community, and empowered to address the full spectrum of a child’s needs—medical, behavioral, and social.  

From San Diego to Riverside: Scaling Pediatric ECM Through Partnership 

What began as a local ECM initiative at Rady Children’s Hospital is now expanding regionally, thanks to robust infrastructure and deep partnerships. Supported by PATH CITED funding, Rady’s ECM program has grown from San Diego County to Riverside County, helping to fill a critical gap in pediatric ECM services in the Inland Empire. 

Through a partnership with Inland Empire Health Plan (IEHP), Rady Children’s Hospital has adapted its pediatric-focused model, rooted in whole-child care, family-centered planning, and teamwork between departments, to serve a wider area while maintaining quality and outcomes. Their Epic-based referral and tracking system maintains continuity across counties, while their REDCap and health-plan specific workflows support consistent documentation, regardless of location. 

This model is designed to grow, with thorough staff training and mentorship across different sites. Training includes motivational interviewing, integrating behavioral health, and providing culturally competent care. Regular meetings between teams across counties support learning and lead to improvements in the program. 

Rady Children’s Hospital is already making a difference for families in Riverside. For example, one young patient  with Type I Diabetes, autism, and serious mental health needs had difficulty accessing mental health services, receiving Applied Behavior Analysis (ABA) therapy, managing their diabetes, and finding a dental home that accommodates children with autism. 

Thanks to ECM, this patient now receives at-home ABA therapy services and is connected to a dental home that the patient and their family love. The individual is also connected with Rady’s Murrieta Developmental Evaluation Clinic, where they access mental health services, and their family receives guidance on managing behavioral concerns. 

Additionally, their ECM LCM connected them with Rady Children’s in-house RN Care Navigation for diabetes management. They even received a Sunshine Box from Friends of JoJo’s, filled with age-appropriate therapeutic toys and activities, along with a referral to an art therapy group, adding even more support to their care. 

“As we grow, we remain committed to the principles that make pediatric ECM work: hiring from within the communities we serve, designing systems that support families’ real-world needs, and centering every effort around improving the lives of children with complex medical and social needs,” said Russell Gagui, RN, Manager of Enhanced Care Management at Rady Children’s Hospital in San Diego. 

Navigating Complex Needs Through a Whole-Child Lens 

Children and families eligible for California Children’s Services (CCS)often face unique barriers to care, like accessing specialty care, transportation issues, and social drivers of health. Rady Children’s Hospital has designed their Enhanced Care Management (ECM) program to meet those challenges head-on with a best practice framework centered around three principles: pediatric expertise, seamless care navigation, and a whole-child approach. 

Lead Care Managers (LCM) act as “air traffic control” for families of children with complex medical needs, particularly those without a primary care doctor. Using Epic and REDCap together, Rady Children’s Hospital has built a system that helps health care providers refer patients easily, share information consistently, and collaborate in real time across departments. The system also tracks important social factors affecting health (like housing or food insecurity) and ECM outcomes, which helps improve care. 

LCMs work with specialty clinics, community partners, and Medi-Cal managed care plans to align care and remove access barriers. For example, a 21-year-old patient who had undergone a heart transplant faced a series of daunting challenges like accessing transportation, food insecurity, and being suddenly evicted from their home. Their LCM stepped in to help by quickly connecting them to housing resources and arranging transportation through the Emilio Nares Foundation so they could make important appointments. The LCM also helped the individual get access to medically tailored meals through Mom’s Meals to address food insecurity. As they transitioned out of Rady’s ECM program, the LCM connected them with their new adult ECM provider, the Community Research Foundation – Healthy YouthConnect, to continue receiving care. These best practices not only improve health outcomes, but they build trust and consistency for families often navigating systems alone. When care is fragmented, families can fall through the cracks, but with a coordinated pediatric-focused ECM model, each family has a dedicated partner to help them manage the complexities of chronic illness, behavioral health, and social stressors.  

“By embedding ECM within a children’s hospital and leveraging tools like Epic and REDCap for real-time, cross-disciplinary collaboration, we ensure that no child is left behind due to system barriers,” said Russell Gagui, RN, Manager of Enhanced Care Management at Rady Children’s Hospital in San Diego. 

“Rady Children’s Hospital’s model does not just close care gaps; they restore continuity, strengthen the caregiver-provider relationship, and help children thrive in every aspect of their lives.”