By Zach Friend
Santa Cruz County’s Health Services Agency (HSA) received a nearly $21 million grant from the Whole Person Care Pilot grant program from the state. The grant program funds locally based initiatives that coordinate physical health, behavioral health, and social services for vulnerable Medi-Cal beneficiaries who are high users of multiple health care systems, and often have continued poor outcomes.
The locally funded pilot program, called “Cruz to Health-Data Connect,” will target up to 1,000 unduplicated adult individuals over the life of the pilot project in the next few years. These are local Medi-Cal beneficiaries who:
- Have repeated incidents of avoidable emergency room use, hospital admissions, crisis and acute psychiatric hospitalizations, or nursing facility placement; and/or
- Have mental illness and have been in long-term locked treatment facility
- Have two or more chronic health disorders involving medications prescribed from categories that represent high-cost chronic health conditions
- Are currently experiencing homelessness; and/or are at risk of homelessness and require intensive supportive housing supports to live in the community due to their mental illness, substance use disorder, and co-occurring health conditions.
The goal of the County’s project is to combine several evidence-based approaches to more effectively and efficiently provide care to individuals with a mental illness, substance use disorder, and co-occurring health condition who are homeless or are at risk for homelessness in the community. The project is designed to support participants to live in the least restrictive setting and improve their behavioral health and other health condition outcomes, reduce costly hospitalizations and visits to the emergency department and more.
Through systematic coordination among public and private entities, these grants identify target populations, share data between systems, coordinate care in real time, and evaluate individual and population health progress. The goal is to make a true and measurable impact on their lives while reducing costs to the system of services this population consumes.
To address the needs of this population, four key components were incorporated into HSA’s model:
- A multidisciplinary team which will include mental health clinicians, primary care clinicians, occupational therapists, nursing staff, medical assistants, housing outreach peer staff, and case managers.
- Assistance in locating and securing housing and in-home supports and services from the multidisciplinary team.
- An integrated health model that will allow in-home remote access monitoring and care for participants. By providing electronic remote access monitoring devices in the home, the participant can relay specific health and behavioral health data back to nursing staff who will triage and communicate that information to the treatment team in order to effectively address issues in real time with the individual.
- Inclusion of family members and peers trained in the evidence-based practice of Intentional Peer Support to provide independent living skills-building and social engagement for community integration to the individuals living in their homes or other community placements.
Housing rentals will be provided using traditional funding through federal programs administered by the U.S. Department of Housing and Urban Development, ‘Shelter Plus Care’ and Veterans Affairs Supportive Housing ‘VASH’ vouchers. Funds from the grant for rental and security deposits will be available and a master leasing program on behalf of the program participants, that designates a local non-profit entity to acquire and hold the lease for the apartments. Clients will receive a variety of services and interventions, including housing transition assistance, housing management and supports and peer support services.
Improving outcomes for this vulnerable population can be difficult, but the County is committed to improving the lives of all in our community. Securing funding from this grant is an important first step in implementing evidenced-based practices that improve outcomes and reduce costs for these higher-risk Medi-Cal beneficiaries.
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