Marin County’s implementation of the Whole Person Care pilot used Federal Medicaid funds matched by local funding to build a sustainable, evidence-based, outcomes-focused coordinated system of care across health and social sectors to serve Marin County’s most vulnerable Medi-Cal beneficiaries more efficiently and effectively. This is part of our work to end Chronic and Veteran homelessness.
Our pilot is now a permanent program, with Whole Person Care as a division within Health and Human Services https://www.marinhhs.org/ which holds the county’s homelessness response work and Coordinated Entry system. Our work is supported by a diverse portfolio of funding sources.
While the initial Federal pilot funding ends at the end of 2021, the foundation built under Whole Person Care continues in 2022 and beyond in these ways:
Being continued by the Whole Person Care Division:
- Housing Case Management, contracted with our community providers
- Other homelessness related services, also contracted with community providers
- WIZARD, our care coordination platform
- Convening a network of continuously-learning-aligned providers who meet regularly
Being continued through CalAIM as implemented by Partnership HealthPlan of California:
- Medical Case Management, under CalAIM Enhanced Care Management
- A variety of new services, under CalAIM Community Supports
- More details here: http://www.partnershiphp.org/Community/Pages/CalAIM.aspx
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 is building 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.
“Marin County's WPC program has given me a access to a true life. Without this chance, I don’t think I’d have the will to go on. At age 63, a network of angels helped me and for the first time they didn’t give up on me. At my age, each minute, each hour if a gift, without housing life was just dark. Now there is a light. Now I have a home. The WPC program and housing voucher has finally given me safety and a chance at a true life… It has given me dignity again.” -- Whole Person Care client, Dec. 2018
- The Marin County Department of Health and Human Services (HHS) and its partners have reduced chronic homelessness by 28 percent since 2017.
- From October 2017 through January 2020, 178 individuals who were experiencing chronic homelessness have been housed.
- The total count of people experiencing homelessness in Marin on a single day is 1,034 individuals, a 7 percent reduction from 2017 to 2019. This is especially notable given significant increases in homelessness across other Bay Area counties.
- A key component to this success has been our ability to create new housing for people experiencing chronic homelessness by pairing Marin Housing Authority’s Housing Choice Vouchers with Whole Person Care (WPC) case management teams. We have created 100 new units of Permanent Supportive Housing in Marin using this approach in the past two years.
- Marin has also implemented a data-sharing and care coordination platform that allows 30 partner agencies to access nearly 1,900 client profiles for vulnerable county residents.
- 17: The percent reduction in Emergency Department visits and among WPC clients after being enrolled in the program
- 20: The percent reduction in incarcerations and among WPC clients after being enrolled in the program.
- 54 and 86: In San Rafael, the percent reduction in EMS transports and police calls, respectively, for people housed through WPC.
- Individuals on Medi-Cal 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, with particular focus on individuals who experience homelessness or are precariously housed.
Participating Entities (Updated April 2, 2021):
- Adopt a Family of Marin
- Bright Heart Health
- Buckelew Programs
- Built For Zero
- Canal Alliance
- Catholic Charities
- Center Point, Inc.
- Central Marin Police Authority
- City of Novato
- City of San Rafael
- City of Sausalito
- Coastal Health Alliance
- Community Action Marin
- 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
- Downtown Streets Team
- Fair Housing Advocates of Northern California
- Gilead House
- Homeward Bound
- Hospice by the Bay
- Kaiser Permanente, San Rafael Medical Center
- Lifelong Medical Care
- Marin Center for Independent Living/Opportunity Village
- Marin City Health and Wellness
- Marin Community Clinics
- Marin County Free Library
- Marin County Sheriff's Office
- Marin Health (Marin General Hospital)
- Marin Housing Authority
- Marin Treatment Center
- North Marin Community Services
- Opportunity Village (MCIL)
- Partnership HealthPlan of California
- Richardson Bay Regional Authority
- Ritter Center
- St. Vincent de Paul Society
- Street Chaplaincy
- Swords to Ploughshares
- The Spahr Center
- West Marin Community Services
 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
 Vogel, D. P. (1993). Patient-focused care. American Journal of Hospital Pharmacy, 50, 2321-2329. Access at Patient-focused care.