Case management

https://www.sfhsa.org/services/disability-aging-services/case-management

California Advancing and Innovating Medi-Cal (CalAIM) Enhanced Care Management (ECM)

https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Home.aspx available to select “Populations of Focus" (POF) that will address clinical and non-clinical needs of highest-need enrollees through intensive coordination of health and health-related services. It will meet beneficiaries wherever they are – on the street, in a shelter, in their doctor's office, or at home. Beneficiaries will have a single Lead Care Manager who will coordinate care and services among physical, behavioral, dental, developmental, and social services delivery systems, making it easier for them to get the right care at the right time. POF: homeless; at risk for avoidable ED/hospital utilization; diagnosed with SMI/SUD; with intellectual & developmental disabilities who also qualify for another ECM POF; living in community who are at risk for LTC institutionalization; adult nursing facility residents transitioning to the community.

Anthem Blue Cross 800-407-4627 https://providers.anthem.com/california-provider/patient-care/calaim
Kaiser Permanente 833-721-6012 https://healthy.kaiserpermanente.org/northern-california/shop-plans/medicaid/calaim-programs
SF Health Plan (SFHP) 415-615-4501 https://www.sfhp.org/providers/our-network/enhanced-care-management/

*DAS ECM (CLF contract with IOA) is SFHP ECM provider for "adults at risk for LTC institutionalization" who meet all 4 criteria: 1) live in community & meet SNF level of care criteria, 2) require lower-acuity skilled nursing (such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, dx, or tx of acute illness/injury, 3) have any social needs (e.g., food insecurity, housing needs, exposure to trauma, social isolation, etc.) that influence their health, and 4) able to reside continuously in community with wraparound supports.

ARCHSTONE-CALAIM-WHITEPAPER-FINAL-Nov-2023.pdf

DAS Community Case Management https://www.sfhsa.org/services/care-support/community-case-management Eligibility: SF resident, age 60+ or age 18-59 w/disabilities, income < 400% FPL, who are at risk of premature institutionalization, and who meet at least one of the following conditions:

Impairment in > 1 ADL (eating, dressing, transferring, bathing, toileting, and grooming), or
Impairment in > 2 IADL (taking medications, stair climbing, mobility indoor, mobility outdoor, housework, laundry, shopping and errands, meal preparation and cleanup, transportation, telephone, and money management), or
Unable to manage his/her own affairs due to emotional and/or cognitive impairment, or
Impaired by significant event or circumstance that has occurred within past 12 months

Services provided: Assess the client's needs and develop a care plan; Authorize, arrange, monitor, and coordinate services; Help with discharge from care facilities. Contact DAS 415-355-6700.

Community partners:

Bayview Senior Services https://bhpmss.org/case-management/

Catholic Charities https://catholiccharitiessf.org/aging-case-management/

Curry Senior Center https://curryseniorcenter.org/programs-category/

Episcopal Community Services (ECS) https://ecs-sf.org/canon-kip-senior-center/

Homebridge https://www.homebridgeca.org/

Institute on Aging (IOA) https://www.ioaging.org/services/ioa-case-management/

Jewish Family Children Services (JFCS) https://www.jfcs.org/find-help/seniors/ (end 7/01/2023)

Kimochi https://www.kimochi-inc.org/social-services-and-family-caregiver-support

On Lok Day Services/30th Street Senior Center https://onlok.org/senior-services/case-management/

Openhouse https://www.openhousesf.org/support-services

Self-Help for the Elderly (SHE) https://www.selfhelpelderly.org/our-services/social-services/case-management

DAS Community Living Fund (CLF) https://www.sfhsa.org/services/care-support/community-living-fund Eligibility: 1) SF resident, 2) age 18+, 3) willing and able to reside in community with appropriate supports; 4) annual income < 300% FPL; assets (excluding assets allowed under Medi-Cal) < $130K single/$195K married, or < $6K for Purchase of Service (POS) only; 5) demonstrated need for service and/or resource that will serve to prevent institutionalization and community living; and 6) be institutionalized or deemed at assessment to be “at imminent risk” of being institutionalized as evidenced by one of the following:

medical condition resulting in functional impairment in at least 2 ADL, or
unable to manage one's own affairs due to emotional and/or cognitive impairment resulting in functional impairment in at least 3 IADLs

Referrals from medical facility/SNF if expected to be discharged in 3 months.

Service provided: Coordinated case management and purchases that may include equipment, modifications to the residence, or needed support services. Service needs include: housing-related, home repairs/modification, furniture/appliances, in-home/attendant services, caregiver support, emergency response, food, medical/dental, assistive devices & DME, day programs, mental health/substance abuse services, case management, money management. Contact DAS 415-355-6700.

https://www.ioaging.org/services/community-living-fund/

Golden Gate Regional Center https://www.ggrc.org/services/case-management

Home and Community-Based Alternatives (HCBA) Waiver https://www.dhcs.ca.gov/services/ltc/Pages/Home-and-Community-Based-(HCB)-Alternatives-Waiver.aspx provides care management services to persons at risk of nursing home/institutional placement. Care management services are provided by a multidisciplinary Care Management Team (CMT) comprised of a nurse and social worker. CMT coordinates Waiver and State Plan services (such as medical, behavioral health, IHSS, etc.), and arranges for other LTSS available in the local community. Care management and Waiver services are provided in the participant's community-based residence. This residence can be privately owned, secured through a tenant lease arrangement, or the residence of a participant's family member. Contact Home and Health Care Management 800-400-0727 https://homeandhealthcaremanagement.com/

https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html

Long, frustrating waits for home care persist despite California expanding program (msn.com)

Does Medicaid Pay for Assisted Living? What You Need to Know (msn.com)

https://www.ioaging.org/services_/home-and-community-based-alternatives

Multipurpose Senior Services Program (MSSP)

https://www.aging.ca.gov/Programs_and_Services/Multipurpose_Senior_Services_Program/ provides both social and health care management services to assist individuals remain in their own homes and communities. MSSP provides on-going care coordination, links participants to other needed community services and resources, coordinates with health care providers, and purchases some needed services that are not otherwise available to prevent or delay institutionalization.

Eligibility: SF resident, age 65+, require Nursing Facility (NF) level of care, not enrolled in another HCBS waiver. Services provided: case management, personal care services, respite care (in-home, out-of-home), environmental accessibility adaptations, minor home repair, transportation, chore services, PERS/communication device, adult day care, protective supervision, meal services (congregate, home-delivered), social reassurance/therapeutic counseling, money management, communication services (translation/interpretation). Self-Help for the Elderly referral/intake: 415-369-2218.

MSSP Waiver provides HCBS to Medi-Cal eligible individuals who are 60 years or older and disabled as an alternative to nursing facility placement. https://www.dhcs.ca.gov/services/medi-cal/Pages/MSSPMedi-CalWaiver.aspx

Eligibility: SF resident, age 65+, Medi-Cal eligible, and eligible for nursing home placement (assistance needed in 2+ ADL)

Nurse and SW care manager conduct initial house call to assess individual’s health, psychosocial, environmental, and rehabilitation needs. SW care manager helps individual develop community living plan to coordinate and facilitate health and social services they need, while providing continuity of care and support so individual can remain living in their desired home environment. MSSP Care management can connect individuals to community services and provide following: transportation, medical care coordination, respite care, home safety modifications, legal assistance, senior companionship, home delivered meals, money management, day activity programs, housing assistance, psychological support services, government benefits, and emergency help with problems such as abuse or eviction notices. Contact: IOA 415-750-1111. https://www.ioaging.org/services/multipurpose-senior-services-program-mssp (end 7/01/2024) https://www.aging.ca.gov/Providers_and_Partners/Multipurpose_Senior_Services_Program/

North Beach Citizens CORE https://www.northbeachcitizens.org/our-work provides case management, incl. access to mailing address, hygiene products, and phones. 1034 Kearny St., SF 94133, 415-772-0918.

SF DPH Intensive Case Management (ICM) or Full Service Partnership (FSP) https://www.sfdph.org/dph/comupg/oservices/mentalHlth/MHSA/ROTS.asp

Screening criteria: MI dx resulting in severe/significant functional impairments/sx that qualify for specialty MH services, and due to functional impairment and circumstances, there is imminent risk of decompensation without tx; primary DSM-5 dx, co-occurring SUD, physical health, cognitive impairment (dementia, TBI, I/DD, physical disability/mobility concerns) AND 2+ inpatient psychiatric hospitalizations in past 12 mos, 3+ crisis episodes in past 60 days (incl. Comprehensive Crisis, Dore Urgent Clinic, Crisis Stabilization and/or PES), jail or other criminal justice involvement, or locked facility (IMD) discharge. Email: icm-service-request@sfdph.org

Partners:

UCSF Citywide https://citywide.ucsf.edu/citywide-focus

Felton https://felton.org/social-services/senior-services/

Hyde Street https://www.hscssf.org/

Westside http://test.westside-health.org/services/adult-mental-health-services

Serving Tenderloin/SoMa:

Glide Walk-In Center https://www.glide.org/program/walk-in-center/ provides assistance in obtaining immediate needs like shelter, hygiene and emotional support. 330 Ellis St./Taylor, SF 94102, 415-674-6012.

Hospitality House Self-Help Centers

Sixth Street Self-Help Center https://www.hospitalityhouse.org/sixth-street-self-help-center.html Case Management team provides individualized counseling and care planning for those who are in need of longer-term services to secure benefits, such as General Assistance, Social Security Income, State Disability and Veteran’s Benefits; emergency, transitional, and permanent housing; substance use counseling and access to treatment programs. 169 Sixth St./Mission & Howard, SF 94103, 415-369-3040.
Tenderloin Self-Help Center https://www.hospitalityhouse.org/tenderloin-self-help-center.html provides case management to address immediate and survival needs, and links individuals to longer-term services, cultural resources, community engagement activities, and socialization opportunities that promote holistic health and wellness. It also provides support and social groups, vocational resources, as well as access to basic amenities (such as street respite, restrooms, phone, email, mail service, and weekly grocery distribution). Through partnership with Harm Reduction Therapy Center, access on-site mental health and substance use counseling daily. Care Through Touch Institute provides weekly healing massage and movement therapy to participants. 146 Leavenworth St./Golden Gate Ave. SF 94102, 415-749-2143.

St. Anthony’s Resource Center https://www.stanthonysf.org/services/resource-center/ connects guests to safety net social services offered by St. Anthony’s Foundation and to network of other available services in the Tenderloin and beyond. 121 Golden Gate Ave./Jones, SF 94102, 415-592-2855.

Dining Room, 121 GG https://www.stanthonysf.org/services/dining-room/
Free Clothing Program, 121 GG, 415-592-2843 https://www.stanthonysf.org/services/clothing/
Medical Clinic, 150 GG, 415-241-8320 https://www.stanthonysf.org/services/medical-clinic/
Father Alfred Center/Addiction recovery for men, intake 415-592-2831 https://www.stanthonysf.org/services/addiction-recovery/
Tenderloin Tech Lab, 150 GG, 415-592-2766 https://www.stanthonysf.org/services/tech-lab/
Workforce Development https://www.stanthonysf.org/services/workforce-development/
Hygiene Hub, 150 GG https://www.stanthonysf.org/services/hygiene-hub/
St. Clare’s Care (safe sleep service inside St. Boniface Church), 133 GG https://www.stanthonysf.org/services/st-clares-care/

Geriatric Care Management (private-pay)

Aging Life Care Association (formerly National Association of Professional Geriatric Care Managers) https://www.aginglifecare.org/ALCAWEB/What_is_Aging_Life_Care/Find_an_Aging_Life_Care_Expert

McPherson Fund Provides a Free Aging Life Care™ Management Assessment to elderly and/or disabled family members* of active military members, veterans, or veterans' elderly and/or disabled family members. (*Family members are limited to spouse, parent, or child) For eligible military families, the McPherson Fund will provide up to 4 hours of an Aging Life Care Professional’s expertise – providing recommendations and referrals for the most appropriate service that fits the specific needs of the Veteran or family member. Apply online at https://www.aginglifecare.org/ALCAWEB/Chapters/Florida_Chapter/Florida_Chapter_MILITARY_CONSULT.aspx

National Academy of Certified Care Managers (NACCM) https://www.naccm.net/verify-cmc/

National Association for Professional Gerontologists (NAPG) https://www.napgerontologists.org/

Society of Certified Senior Advisors (CSA) https://www.csa.us/resources/

Aging Solutions https://agingsolutions.com/

Moonstone Geriatrics https://moonstonegeriatric.com/

Sage Eldercare Solutions https://www.sageeldercare.com/

Senior Alternatives https://bayareaseniorcare.com/services/

Aging Solo Handbook https://iona.org/wp-content/uploads/2024/03/Aging-Solo-Handbook-Final.pdf

Navigating Solo Network: The path to dynamic solo aging starts here!

Resources and Support for Older Adults Living Alone: A Comprehensive Guide (2024)

Resources Are Expanding for Older Adults on Their Own - KFF Health News

A Broken System? A Look into Guardianships and How States Look to Reform the System – University of Cincinnati Law Review Blog (uclawreview.org)