Rick's Story

In San Mateo County, a life-changing healthcare program has helped more than 200 people move out of skilled nursing facilities and into their own homes, empowering them to be active, engaged community members. Health Plan of San Mateo (HPSM) is proud to share their inspiring stories as living examples of how our Community Care Settings Program (CCSP) makes a measurable difference in people’s lives.

From Institutional Care to Independent Living

Rick suffered a sudden series of health crises that started with a hospitalization for sepsis and a blood clot in his leg. Then, in quick succession, he was diagnosed with diabetes, Parkinson’s disease, glaucoma, an enlarged prostate and an atrial fibrillation. In May 2015, no longer able to work and dependent on Social Security and disability for income, Rick had no choice but to live in a skilled nursing long-term care facility. There he met a CCSP Care Manager who enrolled him in the program.

In January 2016, Rick moved into a Daly City apartment that the program found for him. HPSM and IOA coordinated with all of Rick’s current care providers to ensure that their services and the resources CCSP would mobilize complemented each other. One resource was In-Home Support Services (IHSS) to help with cooking and housecleaning. CCSP’s treatment plan also included periodic visits from Rick’s Care Manager and social worker, regularly scheduled primary care appointments at Ron Robinson Senior Care Center, cardiology appointments, physical therapy, therapeutic activities through Community-Based Adult Services and guidance from a dietician. By November, Rick moved to a more affordable apartment in South San Francisco’s Rotary Plaza senior housing complex. “The program has come through with everything I need to live on my own,” he said.

About the Community Care Settings Program

Since 2014, CCSP has transitioned aging and disabled people from skilled nursing facilities into the community so they can live independently with the assistance of a coordinated clinical support team. The program was started as part of HPSM’s Coordinated Care Initiative to help Cal MediConnect members (who have both Medicare and Medi-Cal) live independently as active and engaged community members. HPSM provides CCSP services in partnership with two other organizations. Housing agency Brilliant Corners helps program participants find low-income housing in the Bay Area. Once they do, HPSM and San Francisco’s Institute on Aging (IOA) get program participants the resources they need to seamlessly transition from long-term care into their new homes and flourish in their community.

Praise for CCSP

“CCSP streamlines coordination between multiple providers and resources to give everyone a clearer, more comprehensive picture of each client’s clinical condition. This enables us to place people in the optimal care setting and make their transition from one level of care to another seamless.”

Dr. Susan Huang

Chief Medical Officer, Health Plan of San Mateo

“It is heart warming to see CCSP is able to assist individuals living in long-term care facilities who are willing and able to return to living in the community with additional support.”

Jeannie Mon

Care Manager, Institute on Aging

“What I see with CCSP is seamless coordination between MSSP, IHSS and the Health Plan. The program has enabled a number of my patients to move from skilled nursing facilities back into the community—and thrive there.”

Dr. Susan Joseph

Medical Director of the Ron Robinson Senior Care Center

“CCSP fosters a collaborative, multidisciplinary ‘continuum of care’ between social workers, clinicians, caretakers and housing services that is very effective at moving clients out of nursing homes and back into the community.”

Chris Rodriguez

Deputy Director of San Mateo County Health System’s Aging and Adult Services