Whole person care is a long-held vision that can become reality through the ideas and life work of many care providers and partners across our county, our state, and our nation. With the resources of Alameda County Care Connect, we created an opportunity to deliver a more coordinated approach to care and services that will ultimately lead to optimal independence and health for our consumers.
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AC Care Connect strives to support and promote increased coordination and effective, personalized care across all providers through systems improvements, while including the strength and support of the consumer's personal networks in the care planning. Through standardization of practice, development of universal tools, and sharing of consumer health records, we hope to improve our consumers' experience while engaging in services.
Hannah has been living on the streets for about 2 years. She has a history of 5150s for suicidality and is frequently hospitalized. She also has a chronic health condition that has led to 112 days of medical inpatient stays and 100 ER visits. Hannah has not had any contact with her family in over a year.
Joe, Maria, and their 10-year-old son, Rico, have been living in their car for the last 8 months. Maria experienced a medical emergency over a year ago that caused her to be unable to work for 6 months. During this time, Maria also became dependent on her prescription drugs. Joe also had to take time off work to take care of Maria and Rico. Both were eventually laid off their jobs and lost their apartment when they could no longer pay rent. Maria continues to have medical needs to address her health condition.
Michael will be released on probation after serving 4 years of a 5-year jail sentence and is expected to be released in a week. Michael has been struggling with his substance use for years, which is a large contributor to his strained family relationships and history of criminal offenses. Michael has been involved with a re-entry program in jail and has expressed a strong desire to turn his life around, so that he can be a good father for his young children.
With a web-based Community Health Record (CHR), qualified care coordinators/physicians can access a curated set of information on a person (record created through data sharing) from multiple providers including: physical health (inpatient, ER, outpatient, primary care, etc.), mental health, substance use disorder treatment (SUDT), Housing Resource Centers (HRC), social services and criminal justice organizations throughout the community.
A standardized practice of care coordination with standardized tools (i.e. assessments, shared care plans, etc.) across partners and sectors can greatly improve services and positively impact consumers. This system-wide partnership can also greatly enhance the consumer and family experience in using the services across the system.
Together FAMILY, FRIENDS, COMMUNITY, and FAITH are the informal support network virtually all of us have. Some people have more family and friends, while others have more community or faith. At AC Care Connect, we are intentional in looking beyond the individual consumer to identify who they perceive to be their network and what additional support may be available. We also help the consumer to recognize their personal networks, aspirations, and what they wish to restore of their network. The goal is to integrate and stabilize in the consumer’s community. Doing so better insures the consumer to prevent medical, psychiatric and substance relapse.
Home
Access to permanent, stable housing is important for improving someone’s health and well-being. People with disabilities, mental health challenges, and/or have low incomes may be at risk of homelessness without the right housing options.
In this instance, the homeless care clinic connects Hannah to case management through a housing service provider and she is eventually linked to homeless respite bed housing through the Coordinated Entry system.
Mental Health
Mental health is a sense of well-being emotionally, socially, and/ or psychologically. Mental Illnesses are disorders that affect your mood, thinking, or behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors. Many people have mental health concerns from time to time. Alameda County offers an array of services for individuals and families affected by mental illness.
In the instance with Hannah, her social worker at a homeless health clinic connects with Hannah’s Behavioral Health Care Services housing navigation team along with a psychiatrist and work on a plan with Hannah towards stability.
Physical Health/Medical
This includes hospitals, clinics, skill nursing facilities, emergency first responders, and health plans which work to keep our community members healthy. Alameda County strives to support all community members to connect to a "medical home" – an outpatient provider or clinic that provides ongoing care and prevention services to keep people healthier and reduce unnecessary hospitalizations and use of emergency services.
Over a number of visits, an outreach worker was able to build trust with Hannah and convinced her to visit a mobile health clinic. The mobile health clinic staff was able to get her connected to a homeless health clinic, who not only responded to her health needs, but also connected her with a care coordinator and discovered that Hannah was eligible for services through a Behavioral Health Care Services housing navigation service.
Family/Friends
A group of people who are closely connected and in relationship with one another either by birth, choice, or shared residence. People who love, care and support one another. People who are there for one another in times of need and celebration. Family and friends are a part of one’s community.
Once Hannah’s immediate medical and mental health needs are met, Hannah shares with her care coordinator that she misses her sister terribly, but is afraid their relationship is too damaged. She and her care coordinator agree to include reconnecting with her family as a goal in her care plan.
Home
Access to permanent, stable housing is important for improving someone’s health and well-being. People with disabilities, mental health challenges, and/or have low incomes may be at risk of homelessness without the right housing options. Coordinated Entry, a system of prioritizing housing placements, is being implemented throughout the County to house the most vulnerable.
In the case with Joe, Maria, and Rico, Maria’s medical provider, who was aware of Maria's and her family’s living situation, connects her to a care coordinator to further assess all their needs. They link to housing problem solving services through the coordinated entry system where the housing specialist works with Maria and her family to connect with a family member who is willing to take them in for a couple months, while they look for a more permanent solution.
Physical Health/Medical
This includes the hospitals, clinics, skill nursing facilities, emergency first responders, and health plans that work to keep our community members healthy. All of these organizations play a key role in meeting the health needs of our community members at different levels and stages of care, including care coordinators who help consumers with a variety of life challenges.
Maria’s primary care medical provider is aware of her growing dependence on prescription medication and that she and her family were living in their car. While adjusting Maria's treatment appropriately, he provides a referral to a substance use disorder program to help Maria get further treatment and enter recovery. He links her to Margie, the medical center care coordinator, who conducts an extensive assessment of Maria and her family’s needs, strengths, and challenges.
Margie connects Maria to housing assistance for housing problem solving services. When she learns about Maria and her family’s strong ties to their church, Margie encourages them to continue to go to church for the social and emotional support.
Substance Use Disorder Treatment
Addiction can have devastating impacts on the lives of individuals, families, and communities. Alameda County Behavioral Health Care Services offers a continuum of substance use treatment and prevention resources that treat addiction and promote life-long recovery from alcohol and drugs.
With the help of her care coordinator, Maria connects with a substance use treatment program that works with her primary care provider to develop a plan to help her with her dependence on prescription medication.
Faith
Faith comes in many forms and is different for each person. It is the formal and informal spiritual support that can provide comfort, inspiration and connectedness. Faith includes: church, religion, prayer, hope and belief system.
Even though Joe, Maria, and Rico felt embarrassment about their current living situation, they continue to attend their church. They have many talks with their pastor who reaches out to the congregation to support them. Their church community reach out to Joe, Maria, and Rico and support them emotionally, spiritually, and physically, with offers of childcare, home cooked meals, and donations. Joe, Maria, and Rico feel accepted and loved in this community, which offers them strength and encouragement during this tough time in their lives.
Community
Community is a network of people who share a background, identity, life experience, neighborhood, and/or interest in society. Community can also involve some form of faith.
In addition to being involved with his church, Rico is also involved in his school basketball team. Rico confided in his coach about his mother's health challenges and their living situation. Rico's coach checks in on him and his family regularly and makes sure Rico receives additional support to keep up with his schoolwork. Rico enjoys a sense of belonging with his teammates and his daily practices and games provide him with a welcome distraction from his other challenges.
Mental Health
Mental Health is a sense of well-being emotionally, socially, and/ or psychologically. Mental Illnesses are disorders that affect your mood, thinking, or behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.
The re-entry program Michael is involved with conducts a needs assessment prior to his release and identifies that Michael may be experiencing anxiety while also confirming his need for additional supportive services for substance use. His care coordinator identifies a substance use recovery program as well as an outpatient provider for low to moderate mental health needs.
Family & Friends
A group of people who are closely connected and in relationship with one another either by birth, choice, or shared residence. People who love, care and support one another. People who are there for one another in times of need and celebration. Family and friends are a part of one's community.
Michael's ex-wife, Debra, who is hopeful but concerned about his connections with his old friend and drug habits, agrees to pick Michael up on the day of his release. She is allowing him to stay with her and their two children for 2 weeks, so he has time to find another living situation. Debra has expressed that she did not want Michael back unless he was able to stay clean and sober for at least a year out of jail.
Community
Community is a network of people who share a background, identity, life experience, neighborhood, and/or interest in society. Community can also involve some form of faith.
In this case, Michael chooses not to go back to his old neighborhood, where his former friends still deal and use drugs, among other illegal activities. Michael struggles to find new friends and a new community to call his own, one that would support him and encourages him on a different path in life.
Home
Access to permanent, stable housing is important for improving someone’s health and well-being. People with disabilities, mental health challenges, and/or have low incomes may be at risk of homelessness without the right housing options. Coordinated Entry, a system of prioritizing housing placements, is being implemented throughout the County to house the most vulnerable.
Michael is fortunate that he has a pre-arranged living situation at the time of his release, even if a temporary one. This gives him time to work with various housing support services to identify a more permanent living situation. Prior to release, Michael is given information for the 2-1-1 housing support line to start the process of being assessed for his housing needs as well as connecting him to housing problem solving services.
Substance Use Disorder Treatment
Addiction can have devastating impacts on the lives of individuals and communities. Alameda County Behavioral Health Care Services offers a continuum of substance use treatment and prevention resources that treat addiction and promote life-long recovery from alcohol and drugs.
With the help of his care coordinator from his re-entry program, Michael is able to connect immediately to a drug recovery program. He connects with a counselor for one-on-one support as well as with a support group that meets weekly.
Legal Services
Legal challenges affect individuals, families, and livelihoods. Legal services can help with lending practices, debt, and credit reporting. Services can also help with unfair housing practices, landlord relations, evictions, and foreclosures. Legal services also includes the criminal justice system.
Partnerships between social services, health care, mental health, housing and, criminal justice are all needed for successful re-entry for individuals who are released from jail.
Michael, who has had multiple convictions, is determined to become a good father and turn his life around. His care coordinator from his re-entry program works closely with the jail staff and his probation officer before and after Michael’s release to coordinate services and support. After Michael connects to the service providers for his health, substance use programs, and housing, these service partners all work together to support his success.
What was Alameda County Care Connect (AC Care Connect)?
AC Care Connect was an initiative of the Alameda County Health Care Services Agency (HCSA) to improve care for Medi-Cal eligible residents who face the most difficult combination of physical health, mental health, and housing challenges. This six-year Whole Person Care pilot from 2016 – 2021 was funded by a $168 million demonstration contract from the California Department of Health Care Services for specific and approved services. The initiative allows the use of Medi-Cal funding for services not usually thought of as health care, in particular, housing services.
The goal of AC Care Connect was to make sure Medi-Cal eligible consumers facing complex physical, mental, and housing challenges get the care and services needed to improve overall health and reduce unnecessary crisis system utilization. System-wide changes are focused on consumers receiving regular care from providers and finding a safe place to live. This is an innovative approach to enable providers from different systems (physical health, mental health, and housing) to work together to help people achieve optimal health. Click here to download a flyer about AC Care Connect.
Click here to read, Making Change at the Speed of Trust: Whole Person Care in Alameda County.
What was the purpose of AC Care Connect?
Alameda County is committed to strengthening a system of care that works together to deliver consumer centered care and supporting high need individuals (the people of Alameda County who face highly complex physical, behavioral, and social challenges) to achieve optimal independence and health.
Alameda County’s Safety Net providers are working toward increased coordination and effective, personalized care across all providers through systems improvements, while including the strength and support of the consumer’s personal networks in the care planning. Through standardization of practice, development of universal tools, and sharing of consumer health records, Care Connect aimed at improving our consumers’ experience while engaging in services.
Where is the funding going and how is it being used?
What were the key resources offered to Care Connect consumers?
Four key resources offered included: Care Management, Housing Navigation, Housing Counseling, and Housing Legal Advice.
Care Management
AC Care Connect partnered with the Alameda Alliance for Health and other organizations to provide case management for consumers with complex medical and social needs. This included housing help and outreach, among other intensive services.
Housing Navigation
Intensive Housing Navigation services served Alameda County Care Connect consumers who were literally homeless, prioritized by a Housing Resource Center, and Medi-Cal eligible. Housing Navigation helped clients get permanent housing and other resources that support housing stability, including health care services and public benefits. Housing navigators also helped identify and strengthen community supports, including reunification with family and/or friends, coordinating In-Home Support Services (IHSS) if needed, addressing housing barriers through a housing retention plan, and working with Housing Resource Center staff to ensure clients have access to additional resources. Housing Navigators worked with clients until they are housed, and assisted with a warm hand-off to service providers to the extent necessary for clients to retain housing.
Housing Counseling
Housing education and counseling classes were available to all Alameda County residents. Classes included how to fill out applications, adjust to permanent housing, maintain good relationship with landlords, and more. Individual housing counseling were also available at the end of each class.
Housing Legal Advice
Bay Area Legal Aid (BALA) provides legal assistance to low-income individuals. Not all situations will result in individual representation from an attorney, but BALA will provide advice and referrals to individuals who quality at www.baylegal.org. Free legal advice, referrals and representation is available at 1-888-382-3405 on Monday, Thursday and Friday from 9:30am – 12:30pm, and Tuesday and Wednesday from 1:00pm – 4:00pm. Clients may also call the Bay Area Legal Aid Legal Advice Line for issues regarding housing evictions, benefits enrollment/termination, and other legal concerns related to social/housing/health benefits at 1-800-551-5554.
What happened to Care Connect now that funding ended?
AC Care Connect was a change initiative that engages a wide range of County service providers, and our success depends on adoption of new practices and investment in the new infrastructure. Each of the new services and tools being built as part of AC Care Connect Pilots across the state, including Care Connect, forged the pathway towards the state’s current program known as California Advancing Innovation in Medi-Cal (CalAIM). Much of the success in CalAIM today can be traced to the innovation made possible by the whole person care Medi-Cal waiver pilots across the state.
