Whole Person Care CommunityConnect
Whole Person Care (WPC) is a statewide waiver pilot program for vulnerable Medi-Cal recipients to improve health outcomes and reduce utilization of high-cost services. Contra Costa County Health Services is one of 19 counties participating in the program and received approval for $40M (of $3B total) annually from 2016-2020. CCHS has termed the program 'CommunityConnect' as the core goal of WPC is to increase linkages and services outside of the health system into the larger community. Program Aims include:
- Coordinate health, behavioral health, and social services in a patient-centered manner
- Develop infrastructure to ensure long-term collaboration among participating entities
- Improve beneficiary health and wellbeing through more efficient and effective use of resources
Leveraging many existing teams and services at CCHS, CommunityConnect will focus on the areas of Direct Service Delivery, Information Technology and the Sobering Center. Twelve workgroups have been identified to support the initiatives and will utilize CCHS Blue Zone strategies for process improvement with a systemwide sustainability focus.
Direct Service Delivery
- Funding to expand and improve collaboration among various CCHS divisions.
- Anticipate hiring 150 staff members (Community Health Workers, Public Health Nurses, AOD counselors, Mental Health Clinic Specialists, Housing Navigators) to support service delivery to patients in the Target Population.
- Case Managers will have access to interdisciplinary team members to support care coordination of patients. Additional services available to team members and beneficiaries will include access to Sobering Center Services, Legal Support, Peer mentoring services through NAMI, Payee services, Transportation vouchers, PATCH funding to support transition to board and care facilities.
Information Technology Projects
- Community case management software
- Expansion of ccLink to Behavioral Health
- Expansion of HealthLeads Reach system
- ED information exchanges
- New Homeless Management Information System
- Increased technology collaborations with EHSD
- Increased Data Security
- Increased community data connections
- Mobile technology expansion for patients and providers
- Open short-term sobering center to provide services (AOD, transportation) for intoxicated patients
The target population was identified using a risk model developed from the CCHS Data Warehouse. Pulling information from multiple county systems, patients with high medical, social and utilization risks were identified using a calculated scoring system. Patients eligible for enrollment will be approached for voluntary participation in the program and enrolled in one of two tiers:
- Tier 1 – Medical Case Management, managed by a Public Health Nurse
- Tier 2 – Social Case Management, managed by Social Worker or Community Health Worker
Program participation and funding is dependent on the successful completion of the various IT and programming projects stated in the application. In contrast to PRIME, the majority of these metrics are pay-for-reporting based. Each workgroup will identify additional key performance indicators for their interventions and track through the Contra Costa Performance Improvement system utilizing PDSA documentation templates and report monthly to the CommunityConnect Steering Committee.