Meals on Wheels and Senior Outreach Services: Contra Costa Coordinated Care Initiative

John Muir/Mt. Diablo Community Health Fund

Meals on Wheels and Senior Outreach Services:
Contra Costa Coordinated Care Initiative

As people age, maintaining health typically becomes an increasingly difficult and complex challenge. This is especially so for low-income seniors, who must navigate a complicated, expensive, and technologically driven healthcare system. Meeting the health and wellness needs of this vulnerable population depends on simplifying and coordinating care across diverse systems.

To help achieve this goal, the John Muir/Mt. Diablo Community Health Fund (CHF) has provided grants since 2013 to Meals on Wheels and Senior Outreach Services (MOWSOS), which has been operating in Contra Costa County since 1968 and offers a variety of programs that work together to help keep seniors healthy, safe, and independent in their communities.

The grants – which through 2016 total $611,710 – have enabled MOWSOS to plan, implement and evaluate a three-year initiative aimed at reorganizing, expanding and sustaining its care management services for what in 2016 will be 450 low-income seniors from central and east Contra Costa County. The goal is to have the services more effectively and efficiently assist these seniors with health and wellness support. 

In 2014 – the first year of the implementation – MOWSOS:

  • Created a more integrated intake system that better links clients across programs and provides a consistent customer-focused service.
  • Identified local health care partner organizations (community clinics, hospitals) as program and financial partners to further develop care management program expansion in years two and three.
  • Completed an assessment of the capacity of IT and workflow systems.
  • Established funding mechanisms with existing and potential funders to sustain the expanded program. 

In 2015, MOWSOS:

  • Implemented a comprehensive, HIPAA-compliant, care management database.
  • Formalized a fee-for-service care coordination partnership with a local health care partner organization.
  • Participated in the SCAN Foundation Linkage Lab Academy to prepare to coordinate care with local health systems in ways that are compliant with California’s Coordinated Care Initiative and worked with La Piana Consulting to help adapt SCAN seminar material to MOWSOS-specific concerns.
  • Participated in and evaluation by Harder+Company Community Research which helped MOWSOS:
    • Understand and improve the implementation process.
    • Demonstrate the initiative's effect on seniors and the MOWSOS organization.
    • Ensure the design of the new care management model will be sustainable. 

In 2016, the final year of the organization’s 3-year plan of action, MOWSOS will:

  • Establish fee-for-service partnerships with local hospitals for care coordination.
  • Fully implement its internship program with John F. Kennedy University and Cal State East Bay.
  • Secure sustainable funding for its care management service model.