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Whole Person Care - Cruz to Health

Whole Person Care (WPC) - Cruz to Health is a pilot project authorized and funded under California’s MediCal 2020 waiver to test county-based initiatives to improve care management of individuals with chronic co-occurring health conditions and repeated and avoidable medical and/or psychiatric hospitalizations. Funding for WPC - Cruz to Health also comes from the Mental Health Services Act which funds supportive housing services and the innovative use of telehealth devices to help clients and care teams manage chronic health conditions in more independent and non-medical settings.

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WPC - Cruz to Health is a program funded to improve care coordination within HSA County Clinics. Enrollees of WPC - Cruz to Health must therefore be current County Clinic clients or be willing to transfer their care to a County Clinic for more specialized management of their co-occurring health conditions. 

Project Goals

WPC - Cruz to Health has a primary goal of developing more effective strategies to serve individuals with chronic health conditions and, through an Advisory Council, will work with community health partners to:  

  • Develop a care coordination model with innovative and evidence-based interventions that leverage the strengths of the client and the client’s natural support system
  • Optimize, maintain or prevent further decline in client function
  • Reduce unnecessary, avoidable and repeated emergency room visits and hospitalizations
  • Improve clinical outcomes (i.e. morbidity and mortality)
  • Establish interoperability between electronic health record systems (i.e. HIE, Epic, Avatar) for improved data sharing
  • Create seamless transitions between multiple provider organizations and care sites
  • Develop performance standards for health partners and treatment teams
  • Establish shared accountability across patients, families and provider organizations
  • Shared learning and decision-making

Targeted Risk Factors

WPC - Cruz to Health focuses on adopting and strengthening evidence-based practices to improve healthcare management and outcomes for individuals with the following combination of risk factors:

  • A mental health and/or substance use diagnosis and;
  • At least two of the following:
    • Two (2) or more chronic health conditions
    • Homeless or at risk for homelessness
    • Four (4) or more psychiatric hospitalizations in a 12-month period
    • Two (2) or more medical hospitalizations in a 6-month period
    • Institutional living in the last 12-months or currently living in an IMD or jail
    • Prescribed five (5) or more medications for chronic health conditions

Enrollment Process

Enroll in WPC - Cruz to Health by contacting:

Information

How to Enroll in
Whole Person Care
- Cruz to Health

Contact:
Jorge Mendez
831-454-4904
Send email
or
Kelly DeBaene
831-454-4757
Send email

California Department of Health Care Services (DHCS) Whole Person Care (WPC) Pilot Program Grant is Approved