CalAIM Santa Clara

CalAIM Santa Clara offers enhanced care management. Individuals will be assigned a lead Care Manager who will help coordinate transition out of a skilled nursing facility into a home-like environment. The Care Manager will assist with finding and applying for housing, finding doctors and scheduling appointments, understanding prescription drug medications, getting follow-up services after hospital discharge, setting up transportation, finding and applying for food, and connecting the individual to other community programs and services.

This program began as a pilot through Whole Person Care and then transitioned into CalAIM Santa Clara in 2022. Medi-Cal delivery changed to an Enhanced Care Management model with offerings for community supports in order to prioritize whole person care and healthy living.

Program Staffing

  • Care Managers
  • Occupational Therapist
  • RN
  • Program support staff
  • Supervisors and Senior Manager

Program Services

Support in

  • Finding doctors and getting appointments
  • Understanding prescriptions and medications
  • Follow-up services after you leave the hospital
  • Setting up transportation
  • Finding and applying for food and housing
  • Connecting to other community programs and services
  • Housing navigation
  • Coordinating transition out of a skilled nursing facility into a home-like environment
  • Skilled nursing admissions prevention
  • Securing meals to meet nutrition goals

Eligibility Requirements

  • Be a Santa Clara Family Health Plan (SCFHP) member
  • Have multiple chronic or mental health conditions
  • Have visited an ER or hospital multiple times in the last 6 months
  • Be willing to move to a home from a nursing facility
  • Are in need of a safe place to live

Counties Served

Santa Clara County

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