Health Plan coordinates medical care, housing

CCSP pairs housing with intensive medical assistance to clients who, with support, can stay in the community and out of intensive inpatient facilities. The benefits are twofold, not only does it save money but there are also quality-of-life benefits, said Dr. Margaret Beed, the Health Plan’s chief medical officer.

As a region with an extremely high cost of living and seniors becoming the fastest growing demographic, Beed said it’s critical to offer innovative programs that address local needs.

“We have to do something because there would be no place for these people, there won’t even be spots in facilities because some are already at capacity. So we’re trying to find ways to move people back into the community, which is the right thing to do. The longer you can live in the community with support, the better people feel, the better quality of life and they’re happier,” Beed said.

Begun in 2014, the CCSP is part of the county’s Coordinated Care Initiative for dually eligible Medi-Cal, the state’s version of Medicaid, and Medicare patients. The county works closely with agencies like the Institute on Aging and the housing agency Brilliant Corners to help find low-income housing for those who might otherwise be stuck in a nursing facility.

Through a coordinated, multi-disciplinary effort amongst various departments, clients often receive medical, behavioral health and social services, assistance bathing or dressing, as well as help with food and transportation. For some clients, it also means assistance securing affordable housing.

Solano, who now resides at nonprofit MidPeninsula Housing’s senior community on the coastside, previously lived in a nursing facility. Eventually, he recovered enough to return to the community but had lost his home and needed assistance finding housing and arranging long-term support such as rides to dialysis. In December 2015, he moved into MidPen’s Half Moon Village.

Now, he has the adult day care center next door where he can take exercise classes or play games, he receives regular checkups at home, has help going to dialysis and is able to live in his own apartment.

“There are so many benefits,” Solano said, adding he feels safe and enjoys having his personal space. “I like it here.”

In Half Moon Bay, 12 units at MidPen’s senior community have been set aside for clients like Solano, said Melora Simon, director of the Health Plan’s Adult Demonstration Programs.

“Because these people do have higher needs than your average senior affordable housing dweller, working in partnership with MidPen we’re able to create the mix of onsite and offsite services that really enables people to thrive,” Simon said.

It also helps foster a better sense of community with residents able to relate to one another, she said.

“It enables people to age in place, which is very important to them,” Simon said.

There are also cognitive benefits for seniors as it can be disorienting to be thrust into a new environment such as a nursing home for a long period of time. While there are patients who do need inpatient care, there are those who can return home with the right services, Beed explained.

“These are often people who are very alone, don’t have support, have medical needs that can’t be met if they’re alone,” Beed said. “But with some support, they can live on their own quasi-independently.”

The patients range in experience and age. The youngest is in their 40s and after having a stroke was unable to live alone. The oldest is in their 90s but the average age is around 72. Most of the clients have a functional impairment or physical disability, and many have mobility issues, Simon said.

Thus far, they’ve helped about 190 clients, have high levels of client satisfaction and shown nearly 50 percent cost savings as compared to people remaining in nursing homes or inpatient facilities, according to Beed and Simon.

Aside from Half Moon Village, other housing sites the Health Plan has been able to place clients in include Sequoia Belle Haven in Menlo Park, Alma Point in Foster City and the Rotary Plaza in South San Francisco. Many CCSP participants are also able to stay at their own homes or with relatives.

Clients’ needs vary, but the coordination between various departments such as housing, transportation, social services and behavioral health is key. Some clients are able to have in-home visits from doctors, nurse practitioners, social workers and other caregivers. For clients whose conditions greatly improve after about 18 months, they can go on to a “maintenance” phase that is less intensive, Beed said.

One of the largest challenges is that many of the services that support people remaining in the community — such as housing or transportation — are not directly covered by health insurance. Therefore, having partnerships with other county departments, health care providers, nonprofits and housing providers is critical, Beed and Simon said.

“I think it’s a necessity in our current environment. I think absolutely everybody has to work together in the community and leverage the resources we have to take care of people,” Beed said. “People don’t get well and stay well if they don’t have this kind of support, especially when they’re elderly.”

Visit hpsm.org for more information about the Health Plan of San Mateo.

samantha@smdailyjournal.com

(650) 344-5200 ext. 106

Twitter: @samantha_weigel