What is Alameda County Care Connect (AC Care Connect)?

AC Care Connect is an initiative of the Alameda County Health Care Services Agency (HCSA) to improve care for residents who face the most difficult combination of physical health, mental health, and housing challenges. This five-year (2016-2020) Whole Person Care pilot is funded by a $140 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 healthcare, in particular, housing services.

The goal of AC Care Connect is to make sure people 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.

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What is 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, we hope to improve our consumers’ experience while engaging in services. AC Care Connect is here to help.

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Where is the funding going and how is it being used?

  • Almost half of the AC Care Connect funds are allocated to help people get housed; a new expense allowed by Medi-Cal under the pilot.
  • A portion is allocated to the implementation of a Community Health Record (CHR) data sharing system.
  • Funds are going to improve care coordination across multiple systems throughout Alameda County. They are being used to improve the behavioral health crisis response system and to develop culturally affirmative practices to engage better with consumers. Significant investment is being made in training and sustainability.
  • Funds are also allocated for training to support provider staff in learning to work as an integrated system.
  • A portion of funding is being used to expand substance use treatment.

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What are the key resources offered to the AC Care Connect consumers?

Four key resources are being offered: Care Management, Housing Navigation, Housing Counseling, and Housing Legal Advice.

Care Management

AC Care Connect is partnering with the Alameda Alliance for Health and other organizations to provide case management for consumers with complex medical and social needs. This includes housing help and outreach, among other intensive services.

Housing Navigation

Intensive Housing Navigation services are for Alameda County Care Connect consumers who are literally homeless, prioritized by a Housing Resource Center, and Medi-Cal eligible. Housing Navigation is intended to help clients get permanent housing and other resources that support housing stability, including health care services and public benefits. Housing navigators also help 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 work with clients until they are housed, and assist with a warm hand-off to service providers to the extent necessary for clients to retain housing.

Housing Counseling

Any Alameda County resident can participate in housing education and counseling classes. Classes include how to fill out applications, adjust to permanent housing, maintain good relationship with landlords, and more. Individual housing counseling is also available at the end of each class. Classes are held every weekday. Updated schedules are available at www.bayareacs.org/housing-navigation.

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.

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What happens when the project funding ends?

AC Care Connect is 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 needs a plan attached to continue after the grant ends in 2020.

We are developing a plan so that by 2020, we will have identified:

  • which services need to be sustained,
  • what on-going investments will be needed to maintain infrastructure, (e.g., the Community Health Record (CHR), the Housing Resource Centers); and
  • what it will take to make that happen.

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What is the Alameda County Community Health Record (CHR)?

In mid-2019, Care Connect will be rolling out a Community Health Record (CHR). The CHR aims to bring together data from multiple organizations to better share information among providers and improve care coordination efforts. We all recognize that the current health care delivery system for Medi-Cal consumers is highly fragmented. Often providers are unaware of the outside services being provided to their consumers. Each organization has its own system for documenting consumer care, and most of these systems do not talk to each other.

The CHR will allow qualified care coordinators, physicians and other providers to access a curated set of information on a person from multiple providers including: physical health (inpatient, emergency department, outpatient, primary care), mental health, Housing Resource Centers (HRC), and social services. Providers from different systems with common consumers can collaborate as a team. Consumers will receive more efficient and effective care by allowing providers to share information that improves outcomes and accelerates the delivery of services.

For Providers:

We are currently in a pilot and planning phase of the CHR project. Five organizations are currently testing a Pilot Community Health Record (CHR) tool called PreManage ED. This pilot phase is expected to go through the end of 2018. Once we move beyond the pilot phase, we will include a link to the long term CHR system for qualified care coordinators/physicians. For information on the CHR or to inquire about future participation in the rollout of this system, email us at careconnecthelp@acgov.org.

Does HIPAA permit health care providers to share protected health information (PHI) about an individual with mental illness with a third party that is not a health care provider for continuity of care purposes? For example, can a health care provider refer a homeless patient to a social services agency, such as a housing provider, when doing so may reveal that the basis for eligibility is related to mental health?

  • “A health care provider may disclose a patient’s PHI for treatment purposes without having to obtain the authorization of the individual. Treatment includes the coordination or management of health care by a health care provider with a third party. Health care means care, services, or supplies related to the health of an individual. Thus, health care providers who believe that disclosures to certain social service entities are a necessary component of, or may help further, the individual’s health or mental health care may disclose the minimum necessary PHI to such entities without the individual’s authorization. For example, a provider may disclose PHI about a patient needing mental health care supportive housing to a service agency that arranges such services for individuals.
  • See: www.hhs.gov/hipaa/for-professionals/faq/3008/does-hipaa-permit-health-care-providers-share-phi-individual-mental-illness-third-party-not-health-care-provider-continuity-care-purposes/index.html.

Does HIPAA permit health care providers to disclose PHI that includes criminal justice data to other public or private sector entities providing social services (such as housing, income support, or job training)?

  • “A covered entity may disclose PHI for treatment of the individual without having to obtain the authorization of the individual. Treatment includes the coordination of health care or related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party. Thus, health care providers who believe that disclosures to certain social service entities are a necessary component of or may help further the individual’s health care may disclose the minimum necessary PHI to such entities for treatment purposes without the individual’s authorization. For example, a provider may disclose PHI about a patient needing health care supportive housing to a service agency that arranges such services for individuals.
  • See: www.hhs.gov/hipaa/for-professionals/faq/2073/may-covered-entity-collect-use-disclose-criminal-data-under-hipaa.html

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