Health Home Program (Work in Progress)

In 2018, the Family Bridges Health Home Program will open at the Hotel Oakland building located at 270-13th Street, Oakland, CA. The site will be designed to house an interdisciplinary team of healthcare providers including primary care physicians, behavioral health providers, social workers, and nursing staff to offer the case management services for the most vulnerable seniors and adults facing chronic illness

Highlights:

  • In 2014, Family Bridges’ two Adult Day Healthcare Centers, Hong Fook Harrison and Hong Fook 14th, were selected among eight other California organizations to be part of the Alliance for Leadership and Education’s two year Pilot project testing the Community Based health Home (CBHH)
  • CBHH became the first model in the nation to advance the Triple Aim by allying national health home standards with the multi-faceted Adult Day Health Care (ADHC)/Community Based Adult Services (CBAS) team-based service platform
  • The CBHH models functions through the addition of a Nurse Navigator to the ADHC interdisciplinary team. He or she  is highly trained to understand the highest-risk individuals’ unique challenges and social environments and conducts in depth person centered assessments lending a more seamless care management expertise extended beyond the wall of the ADHC and into the home, and medical and community care settings.
  • The outcomes for the two-year pilot showed reductions in hospitalization rates by 24%, Emergency room visits by 23.6% and 30 day hospitalization readmission to 1.8% compared to National Medicare average of 20%)
  • In 2015, Family Bridges received funding from Hotel Oakland Associates to continue the CBHH after the pilot program had ended. Our Nurse Navigator, became part of the Hotel Oakland Villages’ Health and Wellness Connection, providing case management and nursing consultation and education for the Hotel Oakland residents
  • In 2016, Family Bridges received a $1million grant from the Thomas J Long Foundation, to further develop and implement a State Certified Health Home designed to provide enhance case management services to the most frail Medicaid patients facing homelessness and behavioral health issues
  • In 2018, the Family Bridges Health Home Program will open at the Hotel Oakland building located at 270-13th Street, Oakland, CA. The site will be designed to house an interdisciplinary team of healthcare providers including primary care physicians, behavioral health providers, social workers, and nursing staff to offer the case management services for the most vulnerable seniors and adults facing chronic illness