Transition & Case Management Services

This program is available free of charge to adults of any age who qualify. If you have been living in a Medi-Cal paid inpatient facility and wish to return to community living, you are eligible. You can apply for CCT at any time — there is no waiting period.

1. Outreach & Engagement: Contact and engage the member in their care
2. Comprehensive Assessment & Care Management Planning: Complete a comprehensive assessment with the member and work with them to develop a care plan to manage and guide their care and meet their goals
3. Enhanced Coordination of Care: Coordinate care and information across all of the member’s providers and implement the care plan
4. Health Promotion: Provide tools and support that will help the member better monitor and manage their health
5. Comprehensive Transitional Care: Help the member safely and easily transition in and out of the hospital or other treatment facilities
6. Member & Family Supports: Educate the member and their personal support system about their health issues and options to improve treatment adherence
7. Coordination of / Referral to Community & Social Support Services: Connect the member to community and social services
   

ECM is intended for the highest risk, highest-cost Medi-Cal managed care members with the most complex medical and social needs. The program will provide these members with long-term help coordinating their services across delivery systems to address their needs.

To be eligible for Choice in Aging’s ECM program, members must be enrolled in both a Medi-Cal managed care plan (CalAIM) and Contra Costa Health Plan. Members must also meet the Eligibility Criteria for the following California Department of Health Care Services (DHCS) Population of Focus: “Adults Living in the Community and At Risk for LTC Institutionalization.”

Adults Living in the Community and At Risk for LTC Institutionalization

Overview

Intensive care coordination through ECM can help adults continue to reside in the community who would otherwise have entered an institutional setting for care.

Eligibility Criteria

Adults who:

1) Are living in the community who meet the SNF Level of Care (LOC) criteria: OR who require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury.

AND

2) Are actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with activities of daily living (ADLs), communication difficulties, access to food,  access to stable housing, living alone, the need for conservatorship or guided decision-making, and poor or inadequate caregiving which may appear as a lack of safety monitoring).

AND

3) Can reside continuously in the community with wraparound supports (i.e., some individuals may not be eligible because they have high acuity needs or conditions that are not suitable for home-based care due to safety or other concerns).