Health Home Program

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

The Health Home Mission:
The mission of Family Bridges’ Community Health Home is to prevent unnecessary hospitalizations and emergency room visits by managing our clients’ health and social service needs through comprehensive case management.

Who We Serve:
We aim to serve persons with highly complex medical, cognitive or behavioral health challenges, who are at immediate risk of hospitalization or institutional placement, including:
• Multiple Chronic Conditions
• Repeat avoidable institutional care, high care utilization and/or uncoordinated care
• Moderate to severe cognitive/ mental/ behavioral health conditions and substance abuse
• Homelessness, at-risk for homelessness & home insecurity

Services We Provide:
• Enhanced Care Management – Monitor overall health and well-being of clients
• Connect individuals to needed services and work closely with individuals’ health care providers and entities
• Provide home visits, health education, medical appointment escorts, medication reconciliation, and care coordination

How do you know if you are eligible for the services?
You must be currently enrolled in a Medi-Cal Managed Care Health Plan – In Alameda County, the two plans available are Alameda Alliance for Health or Anthem Blue Cross.
For information on eligibility or enrollment, please call (510) 595-5588. During program hours, the receptionist will direct your call to the appropriate nurse navigator and/or community health worker who speaks your language. After hours, the multilingual message will direct you to the appropriate voicemail box of the nurse navigator and/or community health worker who speaks your language.

Who’s on the program staff?
Family Bridges’ Community Health Home Program staff includes, but not limited to, registered nurse navigators, community health workers, psychologists, occupational and physical therapists, social workers and registered dieticians.

What languages does staff speak?
Our staff members speak Cantonese, Mandarin, Korean, and Vietnamese as well as English.
Is transportation provided for program participants?
If needed, transportation services can be arranged.

What is the Enrollment Process?
• Active Alameda County Medi-Cal Managed Care Health Plan members (of either Alliance for Health or Anthem Blue Cross) who meet the eligibility criteria will be referred to our Health Home and are eligible to enroll.
• Upon receiving the referral, from Alameda Alliance for Health or Anthem Blue Cross, a Family Bridges’ Community Health Home staff will contact the referred member to share information about our Health Home services and to ascertain if the individual wants to enroll.
• If the individual would like to become a member of our Community Health Home, then enrollment and assessment activities will be conducted by a Family Bridges’ multi-disciplinary team to determine the needs of the member.
• An individual not currently an active Alameda Alliance for Health or Anthem Blue Cross member but meeting our Health Home eligibility criteria must first enroll in one of the Medi-cal Managed Care Health Plans before enrolling into Family Bridges’ Community Health Home.

Where is the program located?
The Family Bridges’ Community Health Home is located within the historic Hotel Oakland building at 275 14th Street, Oakland, CA 94612. The site provides a home base for an interdisciplinary team of healthcare providers who offer enhanced care management services for the most vulnerable seniors and adults facing chronic illnesses or homelessness.

What are the program hours?
Monday – Friday 8:00 am – 4:00 pm

How do I contact the center?
For questions and inquiries contact Chrisy Tran, RN, at [email protected] or call at (510) 595-5588