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Health Homes Program

Starting July 1 2019, Santa Clara Family Plan (SCFHP) launched a new Medi-Cal benefit called the Health Homes Program (HHP). The HHP provides extra services at no cost to Medi-Cal members with certain chronic health and/or mental health conditions.

HHP offers SCFHP members:

Care Management Care Coordination Health Promotion
Develop and update a Health Action Plan (HAP) to guide services and care Coordinate care across ALL of their providers Educate members about and support them in adopting healthy behaviors
Transitional Care Member and Family Support Referrals to Community and Social Support Services
Facilitate care transitions between the hospital, nursing homes, other treatment facilities, and home Support the self-management and decision making efforts of members and their family and/or support team Connect members to community and social services, as needed
Housing Navigation and Tenancy Support
Connect members experiencing chronic homelessness with housing and tenancy support

Health Homes Care Team

HHP services are provided through a care team also known as a Community-Based Care Management Entity (CB-CME). The care team/CB-CME is the frontline provider of the HHP required services. They will conduct outreach to SCFHP members who are eligible for HHP, as well as deliver HHP services. The care team includes a care coordinator who will work with the member and their health care providers, such their doctors, specialists, pharmacists, case managers, and others. They will make sure everyone is informed about the member's health and the services they need. The care team will work with the member to manage and coordinate their care and connect them to community and social services.

The HHP Care Team consists of:

  • Care coordinator
  • HHP director
  • Clinical consultant
  • Housing navigator

The HHP Care Team can help SCFHP members:

  • Enroll in the HHP
  • Find doctors and schedule appointments
  • Better understand their prescription drugs
  • Set up transportation to doctor visits
  • Receive follow-up services after a member leaves the hospital
  • Find and apply for food benefits and housing
  • Connect to other community programs and services

In addition to SCFHP providing HHP services, we are working with the following organizations:

Serious mental illness Chronic conditions
  • Community Solution
    • Morgan Hill
    • Gilroy
  • Gardner Health Services
    • Gardner St. James Health
    • Gardner CompreCare Health Center
    • Gardner Downtown Health Center
    • Gardner Health Center
    • Gardner South County Health Center
  • North East Medical Services
  • Roots Community Health Clinic
  • Uplift Family Services
  • Kaiser Permanente*
  • Gardner Health Services
    • Gardner St. James Health
    • Gardner CompreCare Health Center
    • Gardner Downtown Health Center
    • Gardner Health Center
    • Gardner South County Health Center
  • North East Medical Services
  • Roots Community Health Clinic
  • School Health Clinics
    • Washington Neighborhood Health Clinic
    • Franklin McKinley Neighborhood Health Clinic
  • Peninsula Healthcare Connection-New Directions Program
  • Kaiser Permanente*

* Kaiser will only provide HHP services to members enrolled with them.