CommunityConnect is Contra Costa Health Services’ holistic case management program. It is one of the largest pilots in California’s Whole Person Care program. CommunityConnect identifies and addresses social needs not otherwise met by the health system. The program, started in 2017, uses a first-of-its-kind model to identify County residents who are most likely to go to the emergency room or seek out more acute care to meet their urgent social needs, then connects residents with services that proactively meet these social needs.
We do more than just connect people to care — we identify and address what prevents them from getting it. Our skilled case managers help patients assess their needs, set healthcare goals, and coordinate patients’ physical, mental, and behavioral health treatment. Case managers can even help patients figure out transportation to appointments, get a cellphone, and ensure they’re in stable housing where they can take care of themselves and feel safe.
How it Works
Step 1: Based on needs & health histories evaluated by a data-driven risk model, patients are identified, enrolled & matched with a case manager.
Step 2: Case managers conduct a comprehensive & trauma-informed assessment of patients’ social needs, as well as physical & behavioral needs.
Step 3: Then, collaboratively, they develop a plan & health goals for the year— this often includes a dental goal (50% of patients) or a housing goal (33% of patients).
Step 4: Case managers visit with patients & coordinate complex solutions, working with doctors, mental health clinicians, pharmacies, landlords, or legal staff to best meet their needs.
Step 5: Patients are connected to tangible services like security deposit assistance, free legal services, a cell phone to stay connected to providers, or transportation to appointments.