Enhanced Care Management (ECM)

Poor nutrition can lead to poor health, especially for members with chronic conditions. Meals designed by dietitians can help these members reach their nutrition goals at critical times to help them regain and maintain their health.

This service will initially be limited to members who have poorly controlled diabetes. These members have poorly controlled diabetes for at least six (6) months, even after they have received education about diet, lifestyle, and medication. Members who get this service will agree to enroll in Enhanced Care Management or another case management program if appropriate and eligible. Eventually, this service will expand to members with other chronic conditions. This includes, but is not limited to congestive heart failure and chronic kidney disease. CCHP will also expand this service to members with certain challenging life circumstances. This includes members who can benefit from this service after leaving the hospital or skilled nursing facility to go home. This also includes members with conditions that make it difficult for them to care for themselves.

Members who are who are not eligible for this program include:

• Members currently in another medically tailored meals / medical-supportive foods program.
• Members who do not have access to food storage or preparation.
• Members in a skilled nursing facility (SNF)
• Members in hospice.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Members with poorly controlled asthma may have asthma triggers in their home removed or reduced. Physical changes are made to the home environment to ensure the health and safety of the member. The changes enable these members to function in the home safely. Without these changes, the member’s asthma attacks can result in the need for emergency services or hospitalization.

Examples of environmental asthma trigger remediation include, but are not limited to:

• Allergen-impermeable mattress and pillow dustcovers
• High-efficiency particulate air (HEPA) filtered vacuums
• Integrated pest management (IPM) services
• Dehumidifiers
• Air filters
• Other moisture‐controlling interventions
• Minor mold removal and remediation services
• Ventilation improvements
• Asthma-friendly cleaning products and supplies
• Other interventions identified to be medically appropriate and cost-effective

Members with poorly controlled asthma and stable housing are eligible for the service. Members have environmental asthma triggers identified through a home visit, and these triggers can be reduced or removed. Members agree to complete asthma education, including proper use of asthma medication.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Recuperative Care is also referred to as medical respite care. It is short‐term residential care primarily used for individuals who are experiencing homelessness or those with unstable living situations, who are not ill enough to be in a hospital, but are too ill or frail to recover from an illness (physical or behavioral health) or injury in their usual living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post‐discharge treatment while getting access to primary care, behavioral health services, case management, and other supportive social services (e.g, transportation, food, and housing).

At a minimum, the service will include interim housing with a bed and meals and ongoing monitoring of the individual’s ongoing medical or behavioral health condition (e.g., monitoring of vital signs, assessments, wound care, medication monitoring).

This service is currently limited to adult members living in East County, who receive care at Sutter Delta Medical Center in Antioch. The members must:

• Be hospitalized or at risk of hospitalization at Sutter Delta (e.g., in the emergency department at Sutter Delta) or would be harmed if outpatient treatment that the member needs is interrupted or delayed
• Not be medical appropriate for a skilled nursing facility
• Be able to live independently (e.g., does not require 24/7 care and supervision, not appropriate for an Adult Residential Facility (ARF), etc.)
• Be experiencing homelessness or lack of adequate housing to support recovery
• Have a defined home health skilled need that is appropriate for respite that can be effectively addressed in six (6) weeks or less (e.g, physical therapy, occupational therapy, speech therapy, or wound care)
• Be medically appropriate for respite

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Short-Term Post-Hospitalization Housing helps members experiencing homelessness who have high medical or behavioral health needs. This service gives the opportunity for these members to continue their medical, psychiatric, or substance use disorder recovery in a housed setting with necessary supports to help with their recovery immediately after exiting a hospital. This service also enables these members to receive necessary care, case management, and has them begin to access other housing supports, such as Housing Transition Navigation.

This service is currently limited to adult members living in East County, who receive care at Sutter Delta Medical Center in Antioch. The members must:

• Be hospitalized or at risk of hospitalization at Sutter Delta (e.g., in the emergency department at Sutter Delta)
• Be experiencing homelessness
• Have high medical or behavioral health needs
• Not be medical appropriate for a skilled nursing facility or respite
• Be able to benefit from ongoing supports for recuperation and recovery, and other housing supports
• Agree to Housing Transition Navigation Services support
• Agree to and enroll in Enhanced Care Management or another case management program if appropriate and eligible
• Not have financial means to go elsewhere (e.g., motel, hotel, SRO, etc)
• Not be receiving duplicate support from other local, state, or federally funded program
• Not have previously received this service, where they did not cooperate in good faith with Housing Transition Navigation Services and Housing and Tenancy Sustaining Services

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Housing Transition Navigation Services helps members with obtaining housing. It includes screenings, development of housing support plans, help with searches for and securing housing, identifying and securing financial resources for housing, communicating with landlords, helping with the move, and more. Services are based on the member's needs documented in the individualized housing support plan.

To be eligible, members must:

• Be experiencing or at risk of homelessness
• Be enrolled in Enhanced Care Management or another case management program AND
• Be currently within an acute care setting or post-acute setting (e.g., skilled nursing facility (SNF), respite, post-hospitalization stabilizing housing, etc)
OR

• Have a chronic condition sensitive to housing (e.g., diabetes, congestive heart failure, cancer, end‐stage liver disease, end‐stage kidney disease, asthma / chronic obstructive pulmonary disease, substance use disorder, and/or serious mental illness) with at least one hospitalization or two emergency department visits related to worsening these chronic conditions in the past 24 months
• Not be receiving duplicate support from other local, state, or federally funded program

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

This service provides tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured. Services include identification, education, and intervention surrounding behaviors and needs that may jeopardize housing, help with finances and landlord or neighbor disputes, health and safety visits, and more. Services are based on the member's needs documented in the individualized housing support plan.

To be eligible, members must:

• Be at risk of homelessness
• Be enrolled in Enhanced Care Management or another case management program AND
• Be currently within an acute care setting or post-acute setting (e.g., skilled nursing facility (SNF), respite, post-hospitalization stabilizing housing, etc)
OR

• Have a chronic condition sensitive to housing (e.g., diabetes, congestive heart failure, cancer, end‐stage liver disease, end‐stage kidney disease, asthma / chronic obstructive pulmonary disease, substance use disorder, and/or serious mental illness) with at least one hospitalization or two emergency department visits related to worsening these chronic conditions in the past 24 months
• Not have previously received this service, unless good cause is shown as to why additional services would be beneficial and that the member did not lose previous housing due to unwillingness to cooperate in good faith with necessary actions required for this service
• Not be receiving duplicate support from other local, state, or federally funded program

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

This service assists with identifying, coordinating, securing, or funding one-time services and modifications needed to enable a person to establish a basic household. It does not include room and board or payment of ongoing rental costs.

Housing deposits may include:

• Security deposits required to obtain or lease an apartment or home
• Set-up fees / deposits for utilities or service access
• First month coverage of utilities Including, but not limited to telephone, gas, electricity, heating, and water
• First and last month’s rent
• Services necessary for the member’s health and safety (e.g., one-time cleaning, getting rid of pests)
• Goods such as air conditioner or heater, and other medically-necessary adaptive aids and services for the member’s health and safety in the home (e.g., hospital beds, Hoyer lifts, air filters, specialized cleaning or pest control supplies)

Services are based on the member's needs documented in the individualized housing support plan.

Housing Deposits are available once in a member’s lifetime. It can only be approved an additional time with documentation as to what conditions have changed showing why providing this service a second time would be more successful than the first time.

These services must be identified as reasonable and necessary in the member’s individualized housing support plan and available only if the member is unable to meet the expense.

Members must also receive Housing Transition Navigation Services in conjunction with this service. At a minimum, members must have the tenant screening, housing assessment, and individualized housing support plan.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).