Jennifer’s Story

Whole Person Care is a unique pilot program in San Mateo County that combats addiction, homelessness and other chronic problems. It does this by getting different social welfare organizations to address people’s problems as a team rather than separately. San Mateo County Health leads the effort, which includes 15 official partner organizations. As the manager of pilot participants’ medical benefits, Health Plan of San Mateo (HPSM) works closely with all Whole Person Care partners. One of these is the Bridges to Wellness Team (BWT), which has 14 Care Navigators who provide pilot participants with face-to-face case management and personalized referrals to pilot partners with the expertise to help.

Whole Person Care aims to help 5,000 people by 2020. Here is the story of one person whose life has already changed for the better.

From homeless to new mom in her own home 

Jennifer grew up in San Mateo County, but never felt at home. Her parents were drug addicts, and after they lost custody, she cycled through a series of foster homes. In her teens, she started experimenting with drugs and alcohol, which led to addiction in her twenties. Jennifer eventually started using meth, one of the most dangerous and addictive drugs. Unable to hold down a job and pay rent, she wound up living on the streets.

In March 2017, Jennifer became pregnant. Determined to get sober, she enrolled in an intensive recovery program and moved into a family shelter. She was still living there in November, two days before her due date. Jennifer didn’t want to have her baby in a homeless shelter, but didn’t know what choice she had. She couldn’t afford an apartment, and couldn’t work because she attended the recovery program all day every day and had to be at the shelter at night. She just didn’t know what to do.

Fortunately for Jennifer, she became a Whole Person Care participant, and her Care Navigator, Sarah, called the housing organization Brilliant Corners. They found Jennifer a subsidized studio apartment in San Mateo while Sarah secured local county funds to pay the rent.

Putting housing within reach supports Jennifer’s sobriety and ability to care for Noah. But that is just one of the many ways that Sarah helps Jennifer and her other 14 clients. Sarah meets Jennifer at her apartment at least once a week, and they frequently text between appointments. Sarah is so committed that, when Jennifer went into labor on Thanksgiving, Sarah drove her to Stanford University Medical Center and stayed while baby Noah was born.

“Before Sarah, I had no hope,” said Jennifer. “I felt alone. Even though I was trying and going to programs, exploring all the resources I could think of, I felt like it was me against all these people shutting doors in my face. Just having Sarah in my corner makes me more confident and motivated to keep trying.” Sarah acknowledges that “The County has a lot of great services, but they can be difficult to access. I guide people through the system, collaborating with all their service providers. That takes the pressure off so people can live their lives.”

As Jennifer’s Care Navigator, Sarah is the point person for her overall care. Sarah referred Jennifer to pilot partners for psychotherapy (at South County Mental Health), substance abuse treatment (from StarVista) and medical care (through Health Plan of San Mateo). She also connected Jennifer with San Mateo County’s Prenatal-to-Three Program, which helps parents with children age five and under build parenting skills and access the health care system. Sarah continuously coordinates with these resources so everyone can work as a team to help Jennifer. In her Care Navigator role, Sarah is able to foster connections between Whole Person Care partners so they can communicate and collaborate with each other.

Noah now has childcare, which allowed Jennifer to get a job and work 25 hours a week. She also plans to attend school in the fall to become an Alcohol and Other Drug Abuse (AOD) Counselor. “I can focus on other things now instead of where I’m going to sleep tonight,” she said. “I can have long-term goals and get my life back on track.”

Praise for Whole Person Care

"Getting direct referrals from Whole Person Care partners greatly streamlines the housing referral process, allowing us to find suitable housing for people who desperately need it much more quickly."

Nelly To

Program Director, Brilliant Corners

"Whole Person Care brings all parts of the health system together to treat the ‘Whole Person.’ This collaborative care coordination model enables us to help people with complex needs live longer, better lives."

Lucinda Dei Rossi

Manager of the Whole Person Care Pilot, San Mateo County Health System

"The needs of our most complex members often cannot be adequately addressed by our traditional medical care approaches. Whole Person Care allows us to more effectively support and bridge the psychosocial factors that negatively impact a person’s overall health."

Dr. Susan Huang

Chief Medical Officer, Health Plan of San Mateo