How Elemeno Health supports coordinated care

Elemeno Health Alameda Care Connect Case StudyWith the Elemeno Health platform available via any mobile device, case managers at Alameda County Care Connect are able to deliver accurate information and serve their clients in a more efficient and effective manner.

Alameda Care Connect, based in Oakland, California, improves care for Medi-Cal eligible residents who face the difficult combination of physical health, mental health, and housing challenges. The organization ensures that its clients get the care and services they need to reduce unnecessary crisis system use, and achieve optimal health.

Alameda Care Connect utilizes Elemeno Health’s technology to provide their case workers with the most up-to-date resources, so they can better serve clients in the community.

To illustrate how this works, the narrative below uses fictional characters “Hannah” and “Joanne”, but is based on real coordinated care situations and Elemeno Health resources.


Alameda Care Case Study HannahIntroducing Hannah

Hannah has been living on the streets of Oakland, California for about four years. She has a history of substance abuse, has had a number of 5150 incidents for suicide attempts, and has been frequently hospitalized at Oakland’s Highland Hospital for both mental and physical health issues. Hannah has a number of chronic health conditions, including asthma, that has led to more than 75 visits to the emergency room and 130 inpatient days in the hospital in the past three years. She is 32 years old and has not had any contact with her family, which is located in Santa Rosa, California, in more than five years.

Alameda Care Connect Case Study JoannIntroducing Joanne

Joanne is a new case worker with Alameda County Care Connect. Joanne worked for several years for the Contra Costa County Department of Social Services. In her new job for only a few weeks, Joanne was assigned to work with Hannah to help her find a more permanent place to live, and to help her better manage her chronic illnesses and substance abuse.While Joanne is an experienced case manager, she is new to Alameda County and is not aware of the programs and services available to help Hannah improve her quality of life. While there is an abundance of information available on the Internet, there is no centralized web site that contains the information Joanne needs to gather quickly to help Hannah.Joanne collects her community resources, checklists and fliers. Paper resources are constantly out of date, so she has hand-written corrections to hours, contacts and policies. Overwhelmed with stacks of paper, Joanne is ready to go out into the community. She hopes that she has anticipated every social service need and is bringing the right resources to coordinate care for Hannah. If not, she will have to go back to the office to find what she needs, which will delay Hannah’s care.

How Elemeno Health Helps

Alameda Care Connect Elemeno Housing NavigatorAlameda Care Connect uses Elemeno Health’s cloud-based platform to store and manage all their resources in one centralized location. Paper fliers are now digitized into bite-sized content that is easy to search and use.

Using her iPhone, Joanne is able to quickly access the Alameda County Care Connect portal and click on the Housing link for a list of non-profit organizations that develop, own, and manage affordable housing in the East Bay.

With another click she accessed a PDF that listed 18 organizations in the East Bay that help provide affordable housing. Clicking on Bridge Housing, she connects with Shanice, who helps clients like Hannah find stable, affordable housing. Shanice was immediately able to find a bed for Hannah at an Oakland hotel that is participating in “Project Roomkey”, a program by the state of California to provide temporary housing for the area’s homeless population. Once Hannah receives care for her medical conditions, Joanne will work with Shanice to help find Hannah a more permanent, affordable place to live.

Joanne next needed to work on improving Hannah’s physical and mental health.

With just two clicks Joanne is able to access a document on the Alameda Care Connect portal that walks her through the steps needed to connect Hannah with a substance abuse treatment service. The document on the Elemeno platform helped Joanne ask the right questions to determine Hannah’s history with substance abuse, if she was interested in receiving help, and her history with treatment services in the past. Asking the right questions will help Joanne find the best treatment facility for Hannah’s condition.Satisfied that Hannah is a good candidate to receive help, Joanne uses the Elemeno platform to find a phone number and website link for the County’s Substance Use Access and Referral Helpline, which conducted a 20-minute screening interview with Hannah, to provide a referral for the appropriate level of care. Now eligible for treatment, Hannah will receive an appointment time for intake to a facility and be assigned a care navigator to help support her.

Elemeno for Alameda Care Connect PCP

Joanne next needs to connect Hannah with a primary care provider to help her better manage her chronic conditions, primarily her asthma, and keep her out of the area’s hospital emergency rooms and in-patient beds.Joanne searches the Navigator on Elemeno and finds a link that outlines the steps she should take to help Hannah find a doctor. The document includes a list of questions she needs to ask to determine if Hannah should go to a physician she has seen in the past, or if she should find Hannah a new doctor or clinic.

The document also provides instruction about calling the PCP or clinic to register Hannah as a new client, to make an appointment, and the information she needs to gather before visiting the doctor, such as: a list of health questions and concerns; a list of medical conditions; any existing medications she is taking; any discharge paperwork she may have from previous hospital stays; and any other documents that chronicle her medical history.

Since Hannah does not have a car, Joanne will have to organize transportation to the health clinic, which is located in San Leandro, about 13 miles south of Oakland. The document in the portal that outlines the steps needed to find a doctor also includes a link and website for Alameda Alliance LogisticCare, which provides transportation for clients like Hannah by making an appointment five to seven days in advance.

Thanks to the Alameda Care Connect portal built by Elemeno Health, Joanne was able to help Hannah find a safe place to sleep and make appointments to help her with her physical and mental health. The information in the portal was easy to access, was vetted for accuracy, and was presented in a short and easy-to-read format. Without the portal, Joanne would have had to spend hours searching the Internet for available resources and making multiple phone calls to find the help Hannah needs. If Joanne encounters a resource that is incorrect, she can send feedback to her manager and Elemeno within the portal, so that it can be quickly updated.

Once Hannah’s physical and mental health needs are met, Hannah tells Joanne that she misses her younger sister in Santa Rosa and would like to see her but is afraid their relationship is too damaged. She and Joanne agree to make reconnecting with her sister, and her family, a future goal in her care plan, so she can once again lead a more stable life.

 This is a fictional narrative based on real coordinated care services and resources using Elemeno Health. 

Please see our Press Release for more information on Alameda Care Connect and Elemeno Health’s partnership.

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