Health Care Innovation Awards: Project Profile


Project Title: "Ravenswood Family Health Care Innovation Project"
Geographic Reach: California
Funding Amount: $7,302,463
Estimated 3-Year Savings: $6,200,000


South County Community Health Center, Inc. dba: Ravenswood Family Health Center (RFHC) in partnership with Health Plan of San Mateo, San Mateo County Behavioral Health and Recovery Services, Nuestra Casa and Voices of Recovery, is receiving an award to create a health care home for over 19,000 patient visits or 6,400 patients per year over three years living in our southeast San Mateo County, California service area. The majority of patients have diabetes, asthma, serious mental illness and other chronic conditions. The project will train paraprofessional Health Coach/Panel Managers that will, in a responsive and culturally appropriate manner, support and motivate patients to follow and adhere to evidence-based care plans. These Health Coach/Panel Mangers together with a Social Worker and Nurse Care Transition Coordinators will work with the provider to reduce avoidable emergency room visits,  hospital admissions and readmissions, and in overcoming barriers to obtain health and social support services with estimated savings of over $6 million. Over the three-year period, the South County Community Health Center, Inc. Ravenswood Family Health Innovation program will train an estimated 60 health care workers and create an estimated 28 new jobs. These trained workers will support patient-centered medical teams that will manage a panel of patients that include identified high risk, high cost and high care utilizers.

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