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Whole Person Care WHOLE PERSON CARE • • • Going Beyond Medical Services to Help Vulnerable Californians Lead Healthy Lives “Whole Person Care is providing an opportunity for the most vulnerable in our system to have an integrated care experience that collaborates to provide medical care, behavioral health care and social service needs into a systematic delivery model. In addition to the improvements in care, it is requiring the system to break down barriers and join into partnerships for an unprecedented system integration.” — Pam Rogers-Wyman Director of Adult Behavioral Health Services, Santa Cruz County TABLE OF CONTENTS Introduction ..................................................................................................................... 2 Alameda County ............................................................................................................... 4 Contra Costa County ....................................................................................................... 6 Kern County ..................................................................................................................... 8 Kings County .................................................................................................................... 10 Los Angeles County ........................................................................................................ 12 Mendocino County .......................................................................................................... 14 Monterey County ............................................................................................................. 16 Napa County .................................................................................................................... 18 Placer County .................................................................................................................. 20 Riverside County ............................................................................................................. 22 City of Sacramento ....................................................................................................... 24 San Bernardino County ................................................................................................. 26 San Diego County ........................................................................................................... 28 San Francisco County .................................................................................................... 30 San Joaquin County ....................................................................................................... 32 San Mateo County ........................................................................................................... 34 Santa Clara County ......................................................................................................... 36 Santa Cruz County .......................................................................................................... 38 Shasta County ..................................................................................................................40 Small County Collaborative ........................................................................................... 42 Solano County ..................................................................................................................44 Ventura County ................................................................................................................46 CALIFORNIA’S WHOLE PERSON CARE (WPC) PILOT PROGRAM: Many factors impact health. For people in low-income communities, medical problems can be caused and exacerbated by factors related to poverty—also referred to as social determinants of health—including poor nutrition, lack of safe and stable housing, incarceration, unemployment, and the chronic anxiety of income insecurity. Geographic Distribution and Size of WPC Pilots While services may be available to help alleviate some of these stresses and inequities, they can often be delivered in a siloed fashion, where different types of service provid- ers do not regularly communicate or coordinate care, even though they may be serving the same individuals and families. Appreciating the importance of social determinants of health, California’s healthcare and social needs providers are increasingly working together to take a “whole person” approach that extends far beyond traditional health care services. Please note profiles available on 22 of 25 WPC pilots 2 CALIFORNIA’S WHOLE PERSON CARE (WPC) PILOT PROGRAM: Going Beyond Medical Services to Help Vulnerable Californians Lead Healthy Lives Whole Person Care Pilots Looking Ahead California’s current five year Section 1115 Medic- Over the next three years, WPC pilots will aid waiver (known as Medi-Cal 2020) includes identify and test new ways to bridge the silos a $3 billion pilot program to improve care for in California’s safety net system, with the a subset of complex Medi-Cal beneficiaries potential to spread best practices to improve by supporting local efforts that embrace the health throughout the state and country. The Whole Person Care (WPC) philosophy. California Association of Public Hospitals and Health Systems, the California Health Through a competitive process, the California’s Care Safety Net Institute, the County Health Department of Health Care Services (DHCS) Executives Association of California, and the selected 25 WPC pilots to participate in the California State Association of Counties have program. Each pilot is tailored to the local collected information on the various WPC context and needs of the population it serves. pilots to illustrate the state’s effort to improve Health care and behavioral health providers, the health of the most vulnerable. Individually, social services, and community partners, each profile can be used to underscore the such as housing support organizations, health care innovation occurring locally. work together to identify their highest-need Learn more at caph.org/wpc. clients and provide them with comprehensive, coordinate care. 3 WHOLE PERSON CARE Alameda County Background Lead Entity: Alameda County Health Care Services Agency Whole Person Care (WPC) is a pilot program within Medi-Cal 2020, California’s Section 1115 Medicaid Waiver. WPC Estimated Total Population: 20,000 over the course is designed to improve the health of high-risk, high-utilizing of the 5-year pilot, including an estimated 10,000 patients through the coordinated delivery of physical health, homeless behavioral health, housing support, food stability, and other critical community services. Budget: $28.4 million in annual federal funds, matched by an equal amount of local funding provided by Who does the program serve? Alameda County Health Care Services Agency Alameda County’s WPC pilot, Care Connect or AC Care Connect, targets individuals with complex conditions who are What services are included? receiving care management in one system, but require care coordination that crosses multiple systems. Many of these AC Care Connect’s core care management services bundle individuals are high utilizers of costly services and many are focuses on two groups – patients who are homeless or facing homeless or at risk of becoming homeless. homelessness, and patients with more stable housing. Both tiers include enhanced linkage to substance use What health care and social service disorder treatment, crisis stabilization services, and increased organizations are participating? access to social services, as well as specialized assistance in both getting access to and navigating the county’s existing Twenty-one partner organizations are participating in AC physical and behavioral health delivery system. AC Care Care Connect including: Connect also includes staffing support for behavioral health services. • Alameda Alliance for Health: Medi-Cal managed care organization About half of AC Care Connect’s funding is allocated to provide housing support for approximately 10,000 of the • Alameda Behavioral Health Care Services: Managed care program’s enrollees. AC Care Connect implements eight provider for seriously mentally ill patients, and the lead distinct housing interventions: agency for county’s substance use treatment services • Alameda County Probation Department: Works with • Enhanced Housing Transition Service Bundle for justice-involved individuals patients who require a high level of support to navigate into housing • Alameda Health System: County public health care system • Housing and Tenancy Sustaining Service Bundle to • Anthem BlueCross: Medi-Cal managed care organization support services including household management, • Community Health Center Network: FQHC association with landlord relations coaching, and dispute resolution 42 sites • East Oakland Community Project: Operates the County’s largest homeless shelter • EveryOne Home: housing services organization Other partners include city and county-level public agencies, community organizations, and health care providers. 4 WHOLE PERSON CARE Alameda County • Skilled Nursing Facility Housing Transitions Program How are participants enrolled? for patients who do not meet the medical necessity requirement for supportive housing but lack the resources AC Care Connect uses merged data from multiple sources to transition to independent community settings to identify individuals eligible for the program and drive outreach efforts. AC Care Connect also flags crisis entry
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