Care Management Services Bundle

What We Do

The Care Management Services Bundle builds on the framework and network currently being developed in Alameda County as part of California’s Health Homes Program (HHP). Created by the Affordable Care Act, HHP is a structured set of services targeted to a small subset of the highest cost Medi-Cal population who require the highest level of care coordination and who present the best opportunity for improved health outcomes through HHP services. 

The AC Care Connect Care Management Service bundle includes:

  1. Outreach to and engagement of the target population;
  2. Comprehensive care management including the development of an individual health action plan;
  3. Care coordination, including assistance with meeting transportation needs to appointments;
  4. Health promotion;
  5. Comprehensive transitions of care follow-up, including discharge planning;
  6. Support for member and family; and
  7. Referrals to community services and supports and housing navigation resources.
Who We Serve

Medi-Cal patients who are homeless, and/or high users of multiple systems with continued poor health outcomes.

How We Impact

The bundle includes two tiers – one for those not facing homelessness, and the other for homeless individuals for a total of approximately 1100 individuals through June 2020.

Performance Measures
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Scorecard Result Program Indicator Performance Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy