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    Integrating Social Service and Healthcare Delivery in San Francisco


    By Michael Costa

    The fact that the environments we live in can impact our health status has been well known for many years. The challenge is to interact effectively with individuals with disabilities or chronic conditions, such as HIV, to improve or maintain those individuals’ health, and to allow them to live at home or in the community for as long as possible. It’s a puzzle that requires many types of interventions to solve. Policy wonks, activists, legislators and regulators have generally addressed this challenge on a piecemeal basis, focusing on one aspect of the puzzle or another.

    In San Francisco we like to be at the cutting edge. In 2014, the Board of Supervisors funded a project to plan for integrating Long Term Support and Service (LTSS) delivery with healthcare delivery to reach beyond the piecemeal approach to problem solving. Planning took place through 2015 and involved a wide range of community and home-based service organizations, including On Lok, Meals on Wheels, Project Openhouse, and twelve other adult day health and senior service organizations. This past December, a new San Francisco Bay Area LTSS Network was born, and implementation of the network is underway.

    This network in development will include many types of community service providers, including those organizations that participated in planning as well as those that join the network in the future. Together they will provide a wide range of services, including chronic case management that integrates social services and healthcare, helping transitioning individuals out of the hospital or nursing home back into the community, providing comprehensive assessments to determine the appropriate care path for individuals, and offering other services currently provided by each of the participating organizations.

    The network has a lead agency, the Institute on Aging, which will contract with public and private payers and providers. That means Medi-Cal and Medicare beneficiaries, as well as private payer subscribers, will be eligible for services through the network, depending on the contracts that are signed and implemented.

    The network is currently in the process of securing grants from the San Francisco Department of Aging and Adult Services, and various foundations to help fund further network development. It is also currently in discussions with potential sponsors for initial network pilot programs.

    A number of state and federal program initiatives offer additional opportunities for the network. For example, the U.S. Center for Medicare and Medicaid Services (CMS) has just announced an Accountable Health Communities initiative. This five-year project will promote clinical and community service collaboration and integration involving:

    • screening to identify unmet health related social service needs;

    • referral and navigation services to assist high risk individuals living in the community to access community based services;

    • alignment of clinical and community-based services to make sure services are available and responsive to those living in the community.

    The network is ideally positioned to participate in the initiative, and has begun initial conversations with CMS toward that end. Participation would further help build an integrated infrastructure servicing San Francisco that would last beyond the end of the initiative.

    Ideally, the network holds the promise of helping LBGT individuals with chronic conditions, disabilities, or who simply need some help to remain at home and out of the hospital. It would be a great step forward in the evolution of service delivery to multiple LGBT populations, and deserves our community’s support.

    Michael Costa is a healthcare consultant who most recently served as project director for the SF Bay Area LTSS Network Formation project. Please contact him at for more details concerning the project and resulting network business plan.


    1-MarcyAdelmanDr. Marcy Adelman oversees the Aging in Community column. For her summary of current LGBT senior challenges and opportunities, please go to: