In San Mateo County, a life-changing healthcare program has helped more than 200 people move out of skilled nursing facilities and into their own homes, empowering them to be active, engaged community members. Health Plan of San Mateo (HPSM) is proud to share their inspiring stories as living examples of how our Community Care Settings Program (CCSP) makes a measurable difference in people’s lives.
From Immobility to a Full, Rich Life
Conrado had hip replacement surgery in 2012, which left him unable to walk. The following year, he was put on dialysis for kidney failure. Even though he served as a Navy maintenance crewman for more than four decades, Conrado’s health problems left him unable to pay his mortgage, so his house went into foreclosure. He then moved into longterm care at St. Francis Pavilion Nursing & Rehabilitation Center. After his health improved, Conrado’s doctor knew that he was ready to return to the community, so he recommended him for CCSP.
Enrolling in CCSP placed Conrado at the front of the line for an apartment at Half Moon Village, a senior housing complex for low-income San Mateo County residents. The program arranged for Conrado’s move to a furnished apartment, and in December 2015 he settled in. His CCSP Care Manager visited weekly and collaborated closely with the MidPen Housing staff, which manages the Village, to ensure all his needs were met. She started by registering his children with IHSS as his paid caregivers and coordinating Conrado’s treatment plan with his primary care physician, dialysis provider and physical therapist. Throughout the program, Conrado’s Care Manager scheduled and arranged transportation to his medical appointments, which was important because he still needs to use a walker. While Conrado “graduated” from CCSP in September 2016 at the age of 81, he still lives in the Village. He is glad he was enrolled in CCSP because it gave him “a place of my own where I have many friends.”
About the Community Care Settings Program
Since 2014, CCSP has transitioned aging and disabled people from skilled nursing facilities into the community so they can live independently with the assistance of a coordinated clinical support team. The program was started as part of HPSM’s Coordinated Care Initiative to help Cal MediConnect members (who have both Medicare and Medi-Cal) live independently as active and engaged community members. HPSM provides CCSP services in partnership with two other organizations. Housing agency Brilliant Corners helps program participants find low-income housing in the Bay Area. Once they do, HPSM and San Francisco’s Institute on Aging (IOA) get program participants the resources they need to seamlessly transition from long-term care into their new homes and flourish in their community.
Praise for CCSP
“CCSP streamlines coordination between multiple providers and resources to give everyone a clearer, more comprehensive picture of each client’s clinical condition. This enables us to place people in the optimal care setting and make their transition from one level of care to another seamless.”
Dr. Susan Huang
“It is heart warming to see CCSP is able to assist individuals living in long-term care facilities who are willing and able to return to living in the community with additional suppport.”
“What I see with CCSP is seamless coordination between MSSP, IHSS and the Health Plan. The program has enabled a number of my patients to move from skilled nursing facilities back into the community—and thrive there.”
Dr. Susan Joseph
“CCSP fosters a collaborative, multidisciplinary ‘continuum of care’ between social workers, clinicians, caretakers and housing services that is very effective at moving clients out of nursing homes and back into the community.”