County of Marin Health and Human Services

Whole Person Care

Background

In June 2017, Marin County Department of Health & Human Services (Marin HHS) received approval from the state to begin implementation of the Whole Person Care 1115 Waiver. The vision of the County of Marin’s Whole Person Care Pilot (WPC) is to build a sustainable, evidence-based, outcomes-focused coordinated system of care across health and social sectors to more efficiently and effectively serve Marin County’s most vulnerable Medi-Cal beneficiaries.

The WPC pilot will build upon existing programs and services by implementing a unified, coordinated entry and care management system; by standardizing screening, assessments, and care coordination; and, by promoting bi-directional information sharing and care coordination among providers. The goal for this systems-level change is new, coordinated, and sustainable approaches to meeting the needs of high-risk, high-cost Medi-Cal beneficiaries. 

Underlying Philosophies

The following four philosophies underlie the program’s design and will be central to all services delivered:

  • Housing First: countywide efforts to date have been fragmented and have not advanced a “Housing First” approach.  Nationwide, communities have seen a significant reduction in homelessness and improved health outcomes through the implementation of “Housing First” policies that provides permanent housing as the initial service, followed by other supports based on the individual’s needs and preferences.
  • Trauma-Informed Approach [1]: trauma has affected many persons served by the public welfare system. The WPC Pilot will identify evidence-based and best practice trauma-specific treatment models to address the effects of trauma on an individual’s life and facilitate trauma recovery. The WPC Pilots aims to develop a culture of care, safety, and respect through key workforce development activities, including training participants on the principles of, and evidence-based and emerging best practices relevant to, trauma informed care. 
  • Person-Focused Care [2]: for the WPC pilot, a person-focused care approach aims to decentralize and integrate services across the continuum of care, to cross-train staff from different agencies to implement shared WPC strategies, and, to simplify and redesign work while increasing the involvement of enrollees in their care. The priority is designing and aligning systems to reach and serve the client and communities, rather than requiring target populations to overcome systemic structural or cultural barriers.
  • Social Determinants of Health: the WPC Pilot will universally screen enrollees for the non-clinical barriers that may be interfering with their ability to lead healthy, productive lives. 

Target Medi-Cal Populations:

  • Individuals who experience homelessness or are precariously housed
  • Individuals who experience complex medical conditions, behavioral health issues, and/or lack social supports that interfere with standards of care and result in high utilization and costs.  Specifically, this population includes the top 10 percent of Medi-Cal beneficiaries by spending who have a diagnosis of a mental disorder, substance use disorder, traumatic brain injury, dementia, or opioid use and/or 2 or more chronic conditions.

Participating Entities:

  • County of Marin Department of Health & Human Services
  • County of Marin District Attorney's Office
  • County of Marin Probation Department
  • County of Marin Public Defender's Office
  • Buckelew Programs
  • City of San Rafael
  • Coastal Health Alliance
  • Community Action Marin
  • Downtown Streets Team
  • Healthy Marin Partnership
  • Homeward Bound
  • LifeLong Medical Care
  • Marin City Health and Wellness
  • Marin Community Clinics
  • Marin Housing Authority
  • Marin General Hospital
  • Opportunity Village
  • Partnership HealthPlan of California
  • Ritter Center
  • Senior Access
  • St. Vincent de Paul Society
  • Sunny Hills Services
  • US Department of Veterans Affairs
  • The Spahr Center
  • Whistlestop

Contact Information: 
Ken Shapiro
kshapiro@marincounty.org
415-473-6873 (office)                                                                                       
415-847-3665 (cell)
 

[1] Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Access at SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

[2] Vogel, D. P. (1993). Patient-focused care. American Journal of Hospital Pharmacy, 50, 2321-2329. Access at Patient-focused care.