Alliance for Leadership and Education's Community Based Health Home

California

The Alliance for Leadership and Education's Community Based Health Home (CBHH) model is the first in the nation to advance the Triple Aim by combining national health home standards with the Adult Day Health Care (ADHC)/Community Based Adult Services team-based care platform. CBHH builds on the ADHC model by incorporating nurse navigators into the traditional interdisciplinary care team. Nurse navigators provide "high touch" care coordination, conduct detailed health and psycho-social assessments to determine patients' unique challenges and social environment, make at-home visits and facilitate care transitions as needed. Additionally, they work closely with patients' physicians to help patients adhere to their physician's care plan and address emerging crises as they arise. This unique combination of supports helps stabilize individuals' social, medical and psychological conditions and reduces unnecessary utilization of health services. 

Partner Organizations

• California Association for Adult Day Services
• SCAN Health Plan Community Giving, Thomas J. Long Foundation, San Francisco Foundation (funders)

Target Population

Chronically ill individuals at high risk of institutional placement

Care Team

Primary physician, nurse navigator, ADHC interdisciplinary care team (nurse, physical therapist, student physical therapist, occupational therapist, social worker and dietitian)

Timeframe

2013 - present

Results/ Studies

A 12‐month pre‐ and post‐comparison showed a 24% reduction in hospitalization rates and 24% reduction in emergency department visits. 30‐day readmissions were 2%, compared to an average of 20% for Medicare. A mixed‐methods evaluation of the project will begin in 2018.

Funding

Private grants

Resources

Program description