The Collaborative Care Team (CCT) launched in March 2016 as a Health System collaboration between BHRS, the San Mateo Medical Center (SMMC) and Aging and Adult Services (AAS). It sprang from a need to increase client flow throughout the system’s various levels of care, and prevent clients from becoming “stuck” in an inappropriate or higher level of care than needed, including the SMMC inpatient psychiatric unit and other acute care settings. The goals of CCT are to provide the right level of care at the right time and place, promote clients’ wellness and recovery while assisting facilities with a comprehensive range of services and create cross-divisional collaboration aimed at reducing unnecessary wait times.

CCT is multidisciplinary team which includes a program supervisor, program specialist, deputy public guardian, management analyst and psychiatric social workers.

What is the CCT eligibility criteria?

• Clients hospitalized and deemed difficult to place, due to psychiatric (severe mental illness), medical or co-occurring complex issues for adults 18 and over.
• Any client referred to, or currently residing in, an out of county (OOC) facility or Cordilleras.
• Medi-Cal eligible clients.
• Conserved or on Rep Payee clients.

SMMC is the typical point of entry or referral source for CCT. CCT follows clients from a locked setting, like Cordilleras or an out of county facility, to a community setting. CCT staff attend regular discharge planning meetings, treatment reviews, complex case conferences, forensic committee meetings and Regional Center Mental Health meetings CCT works closely with LPS conservators through Aging and Adult Services, hospital staff, BHRS, contract providers and Health Plan of San Mateo. The team facilitates warm hand-offs to community based programs, such as full-service partnerships and regional clinics. CCT staff interface with many different systems within San Mateo County.

CCT is currently contracted with Cordilleras and 28 out of county facilities. The types of facilities range from locked settings, such as a mental health rehab centers, skilled nursing facilities and state hospitals. The unlocked facilities are mostly enhanced board & care homes and a few regular board and care homes.  An enhanced board & care home is a facility, like Psynergy in Morgan Hill, which provides group and individual therapy, medication management, and room and board.

Since inception, CCT has been tracking programmatic data to capture our outcomes. The data includes the levels of care needed, how long it takes for a client to step up/down from the time a referral is sent, barriers to sending clients to these facilities and readmission to the hospital after being discharged within 30 days.

As of January 31, 2018, CCT has served a total of 253 clients, 77 percent of which have been conserved. Over the last two years, CCT has successfully established relationships and trust with many facilities, which helped improve the client flow to a lower level of care from 10 percent to approximately 37 percent, as of January 2018. In addition, CCT takes pride in making sure our clients stabilize in their current facility so that we can reduce the number of readmissions back to the hospital. We are happy to report that in the last two months, CCT has seen zero readmissions within 30 days of a hospital discharge. 

For more information about CCT, contact the CCT supervisor, Betty Ortiz-Gallardo at (650) 573-3612.