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Engaging Complex Care

November’s HIP Council (HIPC) meeting, featured four new programs focused on improving the health of patients with complex needs through case management services.

Health Homes and Intensive Outpatient Case Management

Elizabeth Murphy, MD, Medical Director at Central California Alliance for Health (CCAH), presented Department of Health Care Services’ (DHCS) Health Homes and CCAH’s Intensive Outpatient Case Management (ICM) program.

Health Homes is a federally funded project aiming to create provider infrastructure, demonstrate outcome improvement, integrate physical and behavioral health, and ensure providers appropriately serve persons experiencing homelessness by reimbursing all levels of case management services. In anticipation of local implementation of Health Homes on January 2019, CCAH formed the ICM program.

The goal of the ICM program is to use case management in the primary care setting to improve health outcomes for patients with high-risk chronic diseases and to decrease avoidable emergency department utilization. ICM aims to complete these goals by targeting CCAH members with four or more emergency department visits/three impatient stays in the last year, in addition to two or more chronic conditions. The foundation for ICM is the staff and patient co-created Health Action Plan which operates as a functional evaluation tool that tracks patient progress and goal achievement throughout the period of care. In Santa Cruz County, ICM funding has been granted to three organizations with a high volume of CCAH patients: Salud Para La Gente, Santa Cruz Community Health Centers, and Santa Cruz County Health Services Agency (HSA).

Cruz to Health: Whole Person Care Pilot Program

Jorge Mendez, Senior Health Services Manager at the County Health Services Agency, introduced Cruz to Health (C2H) – Santa Cruz County’s Whole Person Care Pilot. The pilot project, authorized and funded under the Medi-Cal 2020 waiver, is meant to test county-based initiatives to improve care management of Medi-Cal beneficiaries with co-occurring chronic care conditions and a history of repeated and avoidable medical or psychiatric hospitalizations.

The project seeks to design a care coordination model with evidence based interventions that leverages the strengths of the client to improve clinical outcomes, reduce unnecessary healthcare system utilization, create seamless transitions between providers, and expand interoperability between electronic health records. To do so, the pilot is specifically targeting patients receiving primary care at County HSA clinics who have a mental health and/or substance use diagnosis and at least two additional risk factors such as chronic health conditions and homelessness. The pilot also provides a wide array of services including Housing navigation, case management, and access to a healthy lifestyle.

Central Coast Recovery Options

In Santa Cruz County, an estimated 11,261 individuals have some level of opioid use disorder. Of this number, only a small percentage receive treatment. To address local barriers to opioid use disorder treatment, Mark Stanford, PhD, Director of Medication Assisted Treatment (MAT) Services for Janus of Santa Cruz, concluded the meeting by introducing Central Coast Recovery Options (CCRO). Central Coast Recovery Options is a two-year DHCS grant-funded program to expand MAT services—a proven treatment method for opioid use disorder—using Vermont’s hub and spoke model. In this model, the licensed narcotic treatment program (Janus) acts as a hub for primary care providers (the spokes). As the hub, Janus will act as a mentor and resource by coordinating care, providing financial support for buprenorphine prescribing licensure, enhancing regional learning, and caring for clinically complex patients. As spokes, primary care clinics will provide care to patients with mild to moderate opioid use disorder using MAT with the ability to bi-directionally refer patients to Janus. Over a two-year grant period, Central Coast Recovery Options will help local primary care organizations serve over 2,000 patients throughout Santa Cruz and Monterey Counties.

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