Complex Care Programs

Often these individuals experience multiple health and behavioral health co-morbidities as well as negative social determinants of health. Complex Care is designed to work with clients who may be at risk for avoidable hospitalizations and/or emergency department visits, are unhoused or at risk of homelessness, and/or have multiple health and behavioral health co-morbidities. The goal of the team is to improve quality of life and enhance self-management skills. The program supports these vulnerable populations by reconnecting them with essential healthcare and social services. Additionally, the team encourages clients to make and sustain healthy lifestyle choices related to diet, exercise, medication adherence, substance use and mental health.

While the core staffing is made up of Care Managers, also known as Case Managers or Care Navigators, who provide care coordination services, the team works closely with primary care providers throughout the county to ensure quality health care for all their clients. The Complex Care team also includes a Registered Nurse who provides direct nursing care and assessment. The Complex Care nurse is a part of and works closely with the Mobile Health Clinic’s team to support medically fragile individuals who either cannot or will not access primary care services.

Complex Care secured two amazing opportunities to contract with our partners at the Health Plan of San Mateo to provide Enhanced Care Management services, a new Medi-Cal benefit under Cal-AIM and with Behavioral Health and Recovery Services to provide field-based case management services to clients of three regional clinics.