The following success story describes experiences across multiple Providing Access and Transforming Health (PATH) initiatives.
Community Support Network (CSN) provides supportive housing and care for community members with behavioral health challenges in Sonoma County. As an active member of the PATH initiative, CSN is building its capacity to deliver enhanced care services through its Housing and Wellness Program to individuals experiencing and facing homelessness.
Capacity and Infrastructure Transition, Expansion, and Development (CITED) Funding
PATH CITED funding allowed CSN to hire and train culturally responsive staff, including a director and two bilingual care managers, increasing their ability to advocate for members and connect them to needed care.
The following story is one example of the impact this investment has made on Medi-Cal members:
A Spanish-speaking member came to CSN for help. He was living in his car, battling diabetes, and hungry. The director and a bilingual care manager met with him to better understand his situation and discovered he was ineligible for Enhanced Care Management (ECM) with CSN. They enrolled him in Community Supports while working to connect with his ECM provider, which he didn’t know he had or how they can help.
CSN was ultimately able to find his provider and read his care plan, but the situation was confusing. The provider was not from the local area, and the support the member was receiving was unclear.
After leaving multiple messages, CSN received a call back two months later. While waiting for a response, CSN connected the member to a doctor, accompanied him to an appointment to translate, helped him access diabetes medication, supplied him with food, and placed him in an independent master lease unit with another Spanish-speaking man. CSN helped him apply for income and stabilize his health. They also purchased furniture for him and signed him up for medically tailored meals. At first, his care manager met with him twice a week; now they meet once weekly.
Although CSN did not have the ECM treatment authorization request (TAR), they continued to provide services to the member and advocate on his behalf. In the end, the ECM provider acknowledged they were not providing the services the member needed and agreed to release the TAR.
Today, the member is thriving. His health has stabilized, he is housed, he has access to healthy food, and he feels safe. CSN is focused on helping him map out his next set of goals.
“This is one of many successes CSN’s Housing and Wellness Program has experienced, and this is just the beginning,” said a CSN representative. “Although we are a small nonprofit, we’ve been able to expand our wraparound services using CITED funding and better meet members where they are.”
PATH Collaborative Planning and Implementation (CPI) Initiative
In addition to receiving funding through PATH, CSN has benefited greatly from participating in the CPI initiative. CSN participates in the Southwest Collaborative, where they find meetings encouraging, inclusive, informative, and responsive to providers’ needs.
CSN most recently traveled to McKinleyville to attend a Quality Incentive Program (QIP) and ECM Care Plan presentation involving Partnership HealthPlan of California. CSN networked with community partners to learn about creating a referral process for short-term post-hospitalization housing (STPH) services and met with the ECM auditor and QIP manager. CSN was able to ask detailed questions and, through collaboration, develop an intake note for their ECM care plan so it tells the complete story of the member.
“Being part of CPI was invaluable, and we continue to be grateful for the support we receive through our collaborative convenings,” said a CSN representative.
Technical Assistance (TA) Marketplace Recipient
CSN was also recently named a TA Marketplace recipient. CSN is excited to begin applying for free TA to help them scale their ECM benefit and Community Supports services for Medi-Cal members throughout Sonoma County with housing and substance misuse needs.
“Community Support Network’s Housing and Wellness Program would not be able to provide client success stories if it weren’t for all the support we’ve received through PATH. We extend a heartfelt thank you to CPI, CITED, and the TA Marketplace for propelling CSN’s success.” – CSN representative.
Have you applied for funding to support your organization’s workforce, vendor contracting, IT, community assessment and other Medi-Cal needs necessary to deliver ECM and Community Supports?
Have you joined your local network of CalAIM stakeholders working together to implement quality Enhanced Care Management (ECM) and Community Supports services for members?
Would free coding and billing, client outreach and enrollment, program development, CalAIM implementation and monitoring, and other technical assistance services help your organization meet its Medi-Cal needs?