BETWEEN HEALTH CARE AND COMMUNITY-BASED SERVICES
For decades, community-based organizations have operated as an unofficial extension of the healthcare system, providing a wide range of services that address the Social Determinants of Health to help people thrive in the community, especially after being discharged from emergency departments, skilled nursing facilities, and hospitals. Now that incentives have launched to encourage healthcare to partner and contract with CBOs, SSC is leaning in.
SSC is helping local gero-expert community-based organizations get ready to contract with healthcare so they can expand and improve access to community-based supportive services for older adults.
Our research has shown that newly available Medi-Cal services – including Enhanced Care Management and multiple Community Supports – are under-utilized, and that older adults, especially are not being connected to services that could make a difference in their health outcomes. So SSC is training community-based organizations that serve seniors to refer their clients to CalAIM services.
SSC is performing an environmental analysis to identify needs and gaps, and uncover solutions that will address the unique needs of older people.
SSC is helping organizations develop collaborative solutions in partnership with health entities. Our intent is to improve care coordination across medical and social service organizations to improve health and life outcomes for older adults. One way to improve care coordination is by building a robust, secure means of exchanging data among partnering organizations, and SSC has stepped up to assist community-based organizations in taking advantage of the launch of California’s Data Exchange Framework (DxF).
Over the last two years, SSC worked with CBOs and Kaiser Permanente to design and launch a pilot to address the unique needs of high utilizers at local KP hospitals.
HOW DID WE GET HERE?
For the last six years SSC has been building collaborative relationships with public and private sector entities to improve health and life outcomes for older people who live in our county. Learn more about the work and initiatives that have been leveraged to get us where we are today: