Alameda County Care Connect Performance Measures

What We Do

In order to be enrolled in AC Care Connect, a client must have utilized at least one discrete or bundle service, including:

• Bundle Services
  • Housing Transition or Housing Navigation: intensive case management for clients who are homeless and need assistance getting linked to resources for permanent supportive housing and other housing options
  • Skilled Nursing Facility Transition: intensive case management support for clients transitioning from skilled nursing facilities to connect with stable housing
  • Tenancy Sustaining: intensive case management support for clients who have stable housing but need coaching, tools, resources, and assistance maintaining their current housing situation
  • Care Management: intensive case management support for clients with complex medical needs who may benefit from support addressing social determinants of health
• Additional Services
  • Housing Education
  • Housing Legal Services
  • Care Coordination across the Alameda County care system

Who We Serve

AC Care Connect is designed to focus on patients with the highest medical, behavioral health, social and housing needs. In order to be eligible for AC Care Connect services, a client must be actively enrolled in Medi-Cal and meet one of the following criteria:

• Experienced homelessness in the prior 24 months
• Met frequent user criteria in at least 2 crisis systems
• Enrolled in a comprehensive case management program

How We Impact

We work with our consumers and partners to more closely integrate and coordinate services including health care plans, hospitals, primary care providers, crisis partners, housing providers, local housing authorities, and Alameda County agencies such as: Behavioral Health Care Services, the Public Health Department, Social Services Agency, Housing and Community Development, and Probation. 

What We Do

The Housing Navigation Service Bundle is a key component of services offered through Housing Resource Centers (HRCs). HRCs are the places in Alameda County where the major activities of the Coordinated Entry System happen. Coordinated Entry is a standardized method to connect people experiencing homelessness to the resources available in a community. The U.S. Department of Housing and Urban Development (HUD) requires that every community operate a Coordinated Entry System that assesses and prioritizes people experiencing homelessness for programs and assistance within the region dedicated to meeting the needs of people experiencing homelessness.

Housing navigators located at each of the Housing Resource Centers serve as advocates for homeless individuals throughout the housing process. Housing navigators provide a range of housing services that include:

• Tenant screening, assessment, and presenting housing options to the client;
• developing a housing support plan (using a countywide standardized plan template) to identify preferences and barriers to housing;
• searching for housing and assisting with applications and gathering required documentation; non-medical transportation to ensure access to housing options;
• identifying and securing resources for one-time move-in expenses;
• ensuring living environment is safe and ready for move-in;
• moving coordination; and
• establishing procedures and contacts to support housing retention in the community

The service bundle also includes helping the client access mainstream system resources (i.e. health care services, support applying for public benefits; etc.).  Housing navigation follows a Critical Time Intervention (CTI) approach with an emphasis on developing community supports that can be sustained after the navigation services end. 

Who We Serve

Clients who are chronically homeless and high need and not currently receiving care management are eligible for enrollment in housing navigation services. 

How We Impact

Housing navigators will work with clients until they are housed, and will assist with a warm hand-off to service providers post-housing to the extent necessary for clients to retain their housing. Up to 350 clients will be enrolled in housing navigation services through June 2020. 

What We Do

The Tenancy Sustaining Service Bundle is a key component of services offered through Housing Resource Centers (HRCs). HRCs are the places in Alameda County where the major activities of the Coordinated Entry System happen. Coordinated Entry is a standardized method to connect people experiencing homelessness to the resources available in a community. The U.S. Department of Housing and Urban Development (HUD) requires that every community operate a Coordinated Entry System that assesses and prioritizes people experiencing homelessness for programs and assistance within the region dedicated to meeting the needs of people experiencing homelessness.

Tenancy sustaining services include:

• Identification and intervention for behaviors that may jeopardize housing;
• coaching on relationships with landlords; dispute resolution assistance;
• advocating and linking to eviction-prevention community resources;
• assistance with housing recertification; updating housing support and crisis response plans;
• support in household management skills; and
• providing support and education related to the psychological and practical transition into housing - addressing the change of ‘home’ and familiar location, the potential for isolation, how to pay bills, manage visitors and relationships, etc.

Services are offered using housing-first evidence-based practices, and should support individuals to maintain housing and ensure they have the necessary tools to integrate into their communities, focusing on the core values of health, home, purpose, and community. In addition, Housing Care Managers will work closely with regional health care partners linked with these clients to meet their ongoing health care needs.

Who We Serve

Individuals in permanent supportive housing for less than 24 months including Shelter Plus Care, MHSA, and other permanent supportive housing projects can be enrolled in tenancy sustaining services to ensure housing stability if necessary.  

How We Impact

900 clients will be enrolled in tenancy sustaining services through June 2020, as well as connecting 85% of AC Care Connect clients to health homes.

What We Do

A variety of housing legal services are offered through Housing Resource Centers (HRCs). HRCs are the places in Alameda County where the major activities of the Coordinated Entry System happen. Coordinated Entry is a standardized method to connect people experiencing homelessness to the resources available in a community. The U.S. Department of Housing and Urban Development (HUD) requires that every community operate a Coordinated Entry System that assesses and prioritizes people experiencing homelessness for programs and assistance within the region dedicated to meeting the needs of people experiencing homelessness.

AC Care Connect has contracted with Bay Area Legal Aid to provide the following housing legal services:

• Operating a countywide Legal Call Center (Tenant's Rights Line) to triage legal issues as they relate to housing. 
• Developing and delivering housing legal workshops in five regions of Alameda County in partnership with regional Housing Resource Centers and the countywide Housing Education and Counseling services provider (Bay Area Community Services)
• Providing legal representation, brief services, and advice and counsel for specific qualified and prioritized Alameda County Care Connect clients

In addition, AC Care Connect has contracted with Eden I&R to provide a countywide Call Center by dialing 2-1-1. This is a primary way many persons experiencing homelessness or who are at risk of homelessness first contact the coordinated system and are screened and referred for further assessment and services. The Call Center is staffed with trained operators able to screen, triage, and problem solve with callers, make referrals to mainstream resources, send appropriate callers to the corresponding Housing Resource Center to get assistance, and provide information to callers related to filing grievances on behalf of the system.

Who We Serve

Housing Legal Workshops and the Tenant’s Rights Line are accessible to the public and are geared toward assisting anyone in Alameda County who is literally homeless or experiencing a housing crisis. 

Households eligible to receive individual housing legal services (legal representation, brief services, and advice and counsel) must:

• be living in Alameda County; AND
• enrolled in or eligible for Medi-Cal; AND
• have agreed to enrollment in AC Care Connect; AND
• be literally homeless (HUD homeless definition) or have been literally homeless in the last 24 months

How We Impact

Through the provision of legal services described above, AC Care Connect works to prevent and end homelessness by:

• Helping Medi-Cal enrolled and eligible beneficiaries that are homeless or at-risk of homelessness obtain and maintain permanent housing in the community
• Improving Alameda County Care Connect client outcomes by connecting housing with other critical service systems through regional Housing Resource Centers and other service providers, and participation in countywide data-sharing and care coordination
• Reserving more costly and adversarial legal interventions for situations in which low-cost mediation and conflict resolution strategies prove ineffective in meeting the needs of the clients

What We Do

Relationships with property owners and management companies are cultivated and sustained in order to secure permanent supportive housing units for homeless and formerly homeless people with disabilities supported by a variety of housing subsidy funding sources. Specifically, landlords willing to accept clients and subsidies from HUD Continuum of Care (CoC) and MHSA rental assistance programs are identified and supported when issues arise as a result of their involvement in these programs; coordination with service providers and public housing agencies (Public Housing Authorities and City Housing Departments) involved with managing housing subsidies occurs to ensure landlord concerns are addressed in a timely and appropriate fashion; and a landlord incentive and risk mitigation fund is operated. 

Who We Serve

Medi-Cal patients who are homeless, and/or high users of multiple systems with continued poor health outcomes.

How We Impact

215 new units will be created and 691 existing units at risk of leaving the market will be maintained through June 2020. 

What We Do

The Skilled Nursing Facilities Transition Service Bundle works to obtain and maintain permanent housing for AC Care Connect clients in the community and shorten durations of stay in Skilled Nursing Facilities (SNFs) for clients who don’t have an ongoing medical need. The effort extends the Money Follows the Person Rebalancing Demonstration Program, or “California Community Transitions” (CCT), in Alameda County, which is administered by the California State Department of Health Care Services (DHCS). Under the CCT Program, clients are only eligible for case management services if they are Medi-Cal beneficiaries who have continuously resided in state-licensed health care facilities for a period of 90 consecutive days or longer. The Skilled Nursing Facilities Transition Service Bundle identifies clients as soon as they enter a SNF and immediately begins crafting a housing plan that provides an intensive level of housing navigation to help clients transition into the community as soon as possible.

Who We Serve

Medi-Cal beneficiaries residing in a skilled nursing facility within Alameda County.

How We Impact

Housing navigation services are offered to at least 37 clients during the contract year in order to help clients transition into the community from a skilled nursing facility as soon as possible.

What We Do

The Care Management Services Bundle builds on the framework and network currently being developed in Alameda County as part of California’s Health Homes Program (HHP). Created by the Affordable Care Act, HHP is a structured set of services targeted to a small subset of the highest cost Medi-Cal population who require the highest level of care coordination and who present the best opportunity for improved health outcomes through HHP services. 

The AC Care Connect Care Management Service bundle includes:

1. Outreach to and engagement of the target population;
2. Comprehensive care management including the development of an individual health action plan;
3. Care coordination, including assistance with meeting transportation needs to appointments;
4. Health promotion;
5. Comprehensive transitions of care follow-up, including discharge planning;
6. Support for member and family; and
7. Referrals to community services and supports and housing navigation resources.

Who We Serve

Medi-Cal patients who are homeless, and/or high users of multiple systems with continued poor health outcomes.

How We Impact

The bundle includes two tiers – one for those not facing homelessness, and the other for homeless individuals for a total of approximately 1100 individuals through June 2020.

What We Do

AC Care Connect works with partners to get patients discharged from an inpatient psychiatric facility connected to outpatient follow up care within 7 days at best or 30 days at a minimum.

Who We Serve

Patients discharged from an inpatient psychiatric facility

How We Impact