Alameda County Health Care Services Agency (HCSA) has been awarded more than $140 million by the California Department of Health Care Services for an ambitious and innovative program that aims to improve health outcomes for the homeless and other high utilizers of health care services while reducing avoidable costs. Other jurisdictions in California also received grant funding.

The program, known as AC Care Connect, focuses on people experiencing homelessness, people who are high utilizers of multiple systems, including emergency services, hospitalizations, and law enforcement, and people with complex conditions who need care coordination across multiple systems in order to obtain good treatment outcomes. An estimated 20,000 people will be touched by the program over five years.

“Everyone in the United States, rich or poor, has a hard time getting whole-person care,” says Kathleen Clanon, MD, HCSA’s Medical Director. “We treat people as though they were a collection of separate medical problems. Only the most fortunate and persistent patient is able to bring all the pieces together to form a coordinated treatment plan.”

“For people who, in addition to medical problems, are poor, mentally ill, or struggling with addiction, this challenge is often insurmountable. As a result, they cycle through crises without getting better and frequently land on the street.”

“By 2020, AC Care Connect will help some 20,000 Alameda County residents who face the toughest combination of physical, mental, behavioral, and social obstacles bring together the pieces of their treatment, keeping them out of emergency rooms and off the streets and breaking the cycle of expensive and ineffective piecemeal care,” says Dr. Clanon.

The pilot program includes five core initiatives: organizing health care providers, housing, behavioral health, probation, and other systems to work together to better coordinate care; helping patients obtain housing; implementing technology to enable communications and coordination between providers by creating a “community health record”; training and process improvements to promote learning and improve results; and strengthening linkages to integrated health care, including primary care, substance use treatment, and behavioral health care.

“We’ve never really had a coordinated system of care,” says Wilma Chan, Alameda County Supervisor and Chair of the Board of Supervisors’ Health Committee. “Take someone who is alternating between living on the streets and in shelters, receiving services from various agencies, and who maybe suffers from a serious mental illness and who has had multiple emergency room admissions and hospitalizations. Right now, there’s no efficient way for the agencies and institutions serving this person to talk to one another. AC Care Connect is going to help us build a system where the right hand will know what the left hand is doing so we can stabilize people and get them the help they need.”

AC Care Connect comes at a time of increased public awareness of the need for affordable housing. “Communities across the country and now, the State and federal government, are recognizing that people can’t get better if they don’t have a place to live along with supportive services that help them stay housed,” says Robert Ratner, MPH, MD, Housing Services Director of Alameda County Behavioral Health Care Services. “Housing is health, which means that getting people into housing has to be part of an integrated approach to providing health care.”

AC Care Connect includes funding to help people find housing; education, legal assistance, and supportive services to help people stay housed; support for landlords and community living facilities to create more affordable housing options; and funds to help people step-down from skilled nursing facilities to less expensive and more appropriate housing placements.

County and city agencies, health plans, health care and social services providers, housing authorities, advocacy groups, consumers, and others are participating in the project. “I’m excited about this partnership,” says Dr. Clanon. “We have a real chance to reduce homelessness and suffering in our community.”

Funding for the AC Care Connect program is provided by the federal government through what is known as an 1115 waiver, which in California is known as “Medi-Cal 2020.” Waivers allow states to spend Medicaid dollars flexibly for innovative programs. The grant will fund half of the overall program cost, with Alameda County contributing an equal amount.