Case Management and Other Care Coordination Services

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Case Management (CM) is a free benefit for Contra Costa Health Plan (CCHP) members. Case Management programs work to help you with your health needs. Case Management staff helps you get the care you need to stay healthy by connecting you to the right services and resources. Nurses, social workers, and others are here to work with you. They also work with your family, your primary care provider, and others in your health care team.

Case Management Services Help CCHP Members:

Find health care and social services resources
Access referrals to community and social support services
Connect to transportation, interpreter, health education, and other resources
Prevent and manage chronic health conditions and other health issues

Case Management programs each offer a different level of care, so that you get the right care. A Case Manager will talk with you over the phone to see what kind of support you may need to improve your health. A case manager will enroll you into the best program for you. Services are voluntary. You may decline or stop services at any time.

To learn more about these programs, view the program details below.

How to Ask for Case Management Services:

If you have questions or want to enroll, call CCHP Case Management at 925-313-6887 (TTY 711). Ask for case management services. If you are not able to reach someone, please leave a message that includes the best times to reach you.
Talk to your primary care provider (PCP) about a referral to case management services.

Interpreter services are free and available for your language.

Community Health Worker (CHW) Services

Your provider may suggest Community Health Worker (CHW) services for you. A CHW gives you the help you need to live a long life. This includes support for a healthy mind and body. Services may help you prevent and control disease, disability, and other health conditions.

CHWs have lived experience that helps them connect with you. They may live in your community and speak the same language. They may have the same race, ethnicity, sexual orientation, gender identity, or culture.

Services may include:

Help with scheduling health appointments. They can also help you complete medical papers and connect you to community resources.
Health education. They can teach you how to prevent and control chronic diseases. They can also help you learn more about mental health, maternity care, and dental care.
Health promotion and coaching. This can include goal setting and creating action plans to reach those goals.

To find a CHW, you can:

Ask your PCP.
Go to the provider directory online search tool and look for “Community Health Worker” under specialty.
Call Member Services at 1-877-661-6230 (TTY 711) (option 2), Monday – Friday, 8AM – 5PM for help finding a provider.

Care Coordination

The Care Coordination Program helps members get the care they need. Your care team works with you so that you build natural support networks. This kind of support can help improve your independence and wellness.

Who is Eligible?

Any CCHP Member who needs help and support with:

Moving through the health care system. This can mean making appointments and finding providers. This can also mean appointment reminders
Linking to community resources that impact health, including public benefit programs
Referrals to the right services and support programs

Transitional Care Services (TCS)

Transitional Care Services (TCS) help members move from one setting or level of care to another. This program helps you get the support you need for a safe transition of care. It ensures that you get the right services when you leave your stay at a healthcare setting. This may include a hospital or Skilled Nursing Facility (SNF). This support continues as you move to a home or community setting. Other places of care that you may transfer to are Community Supports or Long-Term Care (LTC) settings.

Who is Eligible?

Any CCHP Member who moves from one setting or level of care to another.

Services may include:

Reviewing discharge plans with members
Reducing medication errors for members
Planning and following up on services as outlined in the discharge plan
Supporting discharge plans that connect you to all needed services and supports. This also includes looking into issues that may arise
Working with other members of your care team
Enrolling in appropriate ongoing case management services

Complex Case Management

Complex Case Management (CCM) is for members who need extra support with their health needs. This program helps those who may have complex health conditions. CCM gives ongoing support to help with your chronic health care needs. It also helps with temporary health issues or needs that may arise. This extra support helps prevent the need for hospital and emergency room visits. The goal is to help you reach your best health in the right setting.

Who is Eligible?

CCHP Members who need extra support and help with managing complex health conditions. Members with these needs tend to have frequent hospital and emergency room visits.

Complex Case Management (CCM) is for members who are not eligible for or decline Enhanced Care Management (ECM). If you are enrolled in ECM, you are not eligible to get CCM services at the same time.

Services may include:

Complete assessment of needs and condition, available benefits, and resources
Personalized care plans
Navigation of the health care system, including making appointments and reminders, and finding needed service providers
Connection to community resources, including public benefit programs
Referrals to appropriate health care and social services and support programs
Transitional Care Services (if already enrolled in CCM)

Enhanced Care Management (ECM)

Enhanced Care Management (ECM) is a program for Medi-Cal members with high needs. It provides extra services to help you get the care you need to stay healthy.

If you enroll in ECM, you will have your own care team. This team includes a Lead Care Manager. This person will talk to you and your doctors, specialists, pharmacists, case managers, social services providers, and others. They make sure everyone works together to get you the care you need. A Lead Care Manager can also help you find and apply for other services in your community.

Who is eligible?

Ask about ECM if you:

Are or might be experiencing homelessness within 30 days. This includes leaving your home to avoid domestic violence
Have avoidable emergency room visits (5+) or unplanned hospital and/or short-term skilled nursing facility stays (3+) within 6 months
Use services from the County Specialty Mental Health (SMH) System, and/or the Drug Medi-Cal Organization Delivery System (DMC-ODS), or the Drug Medi-Cal (DMC) program
Have been released from a prison, jail, or youth correctional facility in the last 12 months
Are at risk of needing Long-Term Care (LTC) or a Skilled Nursing Facility (SNF)
Live in an Adult Nursing Facility and are interested in moving out to the community