Transitional Care/Case Management

Transitional Care/Case Management (TCCM) makes it possible for people with disabilities who receive Medi-Cal to leave nursing facilities and move into their own homes.

TCCM provides support in the following areas:

• Providing case management
• Searching for affordable housing
• Helping individuals to access the In-Home Supportive Services Program
• Assisting in training personal attendants
• Identifying needed healthcare professionals in the community

The target population groups for the TCCM Program are:

• Elderly persons with one or more medical, functional, or cognitive disability.
• Persons with developmental disabilities.
• Persons with one or more physical disabilities.
• Persons with one or more mental health disabilities.

Please click here for TCCM Privacy Notice.

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California Community Transitions (CCT)

The CCT Program is a Money Follows the Person (MFP) program administered by the Department of Health Care Services.

East Bay Innovations (EBI) is a Lead Organization (LO) for the California Community Transitions (CCT) Program through the Department of Health Care Services (DHCS) to help people in skilled nursing facilities transition into a home- or community-based setting. Services are covered by Medi-Cal and are at no cost to the participant.

Through the CCT Program, eligible participants will have access to:

• Comprehensive care planning
• Transition coordination services
• Funding for eligible items in the following categories:
• Home Set-Up (can include first month’s rent and security deposit)
• Home Modifications
• Assistive Technology
• Vehicle adaptations
• Post-discharge care coordination

To qualify for the CCT Program, individuals must:

• Have active full-scope Medi-Cal with no Share of Cost (SOC), or have their SOC met
• Currently reside in a Skilled Nursing Facility (SNF) for at least 60 days or longer
• Desire to transition from the Skilled Nursing Facility (SNF) to the community

California Advancing and Innovating Medi-Cal (CalAIM)

CalAIM provides enhanced care coordination and community support services to help eligible individuals live safely and independently. EBI has partnered with Alameda Alliance for Health to deliver Enhanced Care Management (ECM) and Community Supports (CS). Through CalAIM, participants work with EBI case managers and Regional Center service coordinators to access community resources, improve health outcomes, and receive services that support their housing and overall well-being. Services are covered by Alameda Alliance for Health and are at no cost to the participant.

Enhanced Care Management (ECM)

Enhanced Care Management provides personalized care coordination to help individuals access the healthcare and community services they need. ECM services may include:

• Finding healthcare providers and scheduling medical appointments
• Understanding and managing medications
• Arranging transportation to healthcare appointments
• Connecting to community resources, such as housing supports and nutrition programs
• Coordinating follow-up care after a hospital stay
• Working with healthcare providers, Regional Center staff, and other members of an individual’s support team

Community Supports

Housing Navigation

Housing Navigation services help individuals find and secure stable housing by identifying available housing opportunities, assisting with applications and required paperwork, and connecting them with additional community resources and services.

Housing Tenancy and Sustaining Services

Housing Tenancy and Sustaining services help individuals maintain stable housing after they move in. Services may include developing positive property management relationships, understanding lease responsibilities, resolving housing-related concerns, connecting with community resources, and building the skills needed to maintain long-term housing stability.

Home Modifications

Home Modifications are physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual or enable the individual to function with greater independence in the home to prevent institutionalization.

Examples of home modifications for accessibility include:

• Ramps and grab bars to assist members in accessing the home
• Doorway widening for members who use a mobility device
• Stair lifts
• Making a bathroom and shower wheelchair accessible, such as constructing a roll-in shower
• Installation of specialized electric and plumbing systems necessary to accommodate medical equipment and supplies
• Installation and testing of a Personal Emergency Response System (PERS) for members who are alone for significant parts of the day without a caregiver and otherwise require routine supervision, including monthly service costs as needed

To qualify for CS Home Modifications, individuals must:

• Have Alameda Alliance for Health Medi-Cal managed care plan
• Have a medical need for home modifications for accessibility
• Be at risk of institutionalization

The services are available in a home that is owned, rented, leased, or occupied by the member. For a home that is not owned by the member, the member must provide written consent from the owner for physical adaptations to the home or for equipment that is physically installed in the home, such as grab bars or chair lifts.

To learn more about ECM, CS, and CCT, email ebitccmreferral@eastbayinnovations.org or call 510-618-1580 ext. 38.