Care Coordination & Transitional Care
Our agency is leading the way in transitional care in the North State. We are a Lead Organization for the California Community Transitions (CCT) program, we are a Care Coordination Agency for the Assisted Living Waiver Program (ALWP), and we provide care management services for two CalAIM programs (Enhanced Care Management and Community Supports). In addition, we are a Tenant Referral Organization (TRO) for several 811 housing sites providing wrap around services for our HCBA Waiver clients residing in 811 apartments. We were the first home care agency in the nation to work on the federal 8-1-1 project to transition low-income seniors out of skilled nursing facilities back into the community.
These services can be paid for by Medi-Cal, private insurance, long term care, or private pay (depending on eligibility). Please call for details.
California Community Transitions (CCT)
We are a Lead Organization for CCT, a state-run program that is federally funded through Money Follows the Person (MFP). This program helps low income adults (18 years of age and older) who are living in skilled nursing facilities to transition back into community living (home, apartment, 811 apartment, Congregate Living Health facility or residential care facility). Under this program, we provide transitional care services using Registered Nurses and Social Workers. Visit the state website for more information about this program here.
The goal of the CCT program is to develop a person-centered care plan that promotes individual choice and successful self self-managed care. Our team of Transition Coordinators provide comprehensive care from the skilled nursing facility or hospital back home, and can even help clients find housing if they have no home to go back to. This program links individuals with a variety of Home & Community Based Services that support the individual on an ongoing basis.
Housing and Health Partnerships
Home & Health Care Management is the first home care agency in the nation to provide Transitional Care Services for HUD Section 811 Supportive Housing for Persons with Disabilities. This program transitions low income adults either out of skilled nursing facilities or those who are homeless, back into independent living in their own apartments. Under this program, we provide wrap around services by Registered Nurses, Social Workers and home health aides to enable participants in the program to remain in community living in these 811 apartments.
The Sacramento Bee covered this new and exciting program in May 2015. For more information on how this program is funded and how our agency became involved, read our press release here.
Care Coordination under the Assisted Living Waiver Program (ALWP)
Home & Health Care Management serves as a Care Coordination Agency for the Assisted Living Waiver Program (ALWP) in Sacramento and San Joaquin Counties. HHCM assists Medi-Cal recipients to find placement in participating Residential Care Facilities for the Elderly (RCFEs) and enroll into the ALW program. We then provide case management by Registered Nurses and Social Workers to those individuals we have enrolled into the ALW program.
Care Coordination under the CalAIM Program
As of January 2022, Home & Health Care Management began contracting with Medi-Cal Managed Care Plans to provide Enhanced Care Management (ECM) and Community Supports under the California CalAIM Program. HHCM utilizes Lead Care Managers to assist Medi-Cal recipients to better access services to promote their health care needs. HHCM has current contracts with the following Med-Cal Managed care plans: Anthem, Health Net, California Health and Wellness, Cal Viva and Partnership Health Plan in 31 counties in northern and central California.
Enhanced Care Management (ECM)
ECM will improve Medi-Cal for people with complex needs and who are facing difficult life and health circumstances. It is focused on breaking down the traditional walls of health care – extending beyond hospitals and health care settings into communities.
As a key part of CalAIM, Enhanced Care Management (ECM) is a new statewide Medi-Cal benefit available to select “Populations of Focus” that will address clinical and non-clinical needs of the highest-need enrollees through intensive coordination of health and health-related services. Beneficiaries will have a single Lead Care Manager who will coordinate care and services among the physical, behavioral, dental, developmental, and social services delivery systems, making it easier for them to get the right care at the right time.
Download the factsheet about the CalAIM initiative to advance Enhanced Care Management.
Community Supports (CS)
Home & Health Care Management is also a provider of select Community Support Services, including Housing Transition Navigation, Transitions from skilled facilities and transitions to residential care. Community Supports are designed to address social drivers of health (factors in people’s lives that influence their health). HHCM has contracted with local Medi-Cal Managed care plans to provide many of the pre-approved Community Supports.
Download the factsheet about the CalAIM initiative to advance Community Supports to address social drivers of health.