Care Coordination & Housing Support
Overview
We support individuals with complex medical and social needs through case management and care coordination services in Santa Clara County and surrounding communities. Our team helps individuals navigate healthcare, housing programs, and community resources to improve health outcomes and maintain stable housing. Our right-sized caseloads allow for personalized, relationship-based care that promotes long-term stability.
Medical Case Management
Clinical Case Managers support individuals after a hospital or emergency department visit. Services help people safely transition back into the community by coordinating medical care, behavioral health, housing, and basic needs.
This approach reduces repeat hospital visits and improves overall health outcomes.
Enhanced Care Management (ECM)
Through CalAIM programs, PHC provides Enhanced Care Management for Medi-Cal members with complex health and social needs. Each participant is paired with a dedicated care manager who coordinates a team of healthcare providers and social services.
Housing & Social Services
We help individuals address health-related social needs through Community Supports, including:
- Housing transition navigation
- Housing deposits
- Tenant support and housing stability services
- Community and home transition services
Supportive Housing Services
We support individuals transitioning out of homelessness into permanent housing. Services focus on maintaining housing stability, addressing health needs, and building daily routines that improve quality of life.
Care coordination and housing services are provided by the New Directions team through partner referrals.
Help navigating care and housing.
Support for people navigating healthcare, housing, and community resources across Santa Clara County and surrounding communities. You’ll usually need a referral from a healthcare provider, managed care plan, hospital, housing program, or community partner.