San Mateo County Health Department Aging and Adult Services                         ABOUT HOME The Healthier Outcomes through Multidisciplinary Engagement (HOME) Team is a case management program that targets frequent users of the Emergency Department at the San Mateo Medical Center.   The goal of the program is to reduce the number of Emergency Department visits, while promoting access to primary care and healthier outcomes for clients.  HOME Team was implemented in June 2007 and it is a project led by Aging and Adult Services of the Health Department in collaboration with the San Mateo Medical Center and Human Services Agency.   HOME Team was made possible by a grant from the Silicon Valley Community Foundation.   CLIENT SCREENING HOME Team clients are referred by a number of sources, including referrals from Emergency Department staff, the SMMC Medical Director, Medical Center Social Workers and known-to-medical-system data.   Each potential is screened for eligibility into the program.    REFERRAL PROCEDURE Referral can be made in two methods.  Between the hrs of 7AM-4:30PM, Monday –Friday, anyone can page Tammy Siu Social Work Supervisor of HOME team at (650) 632-1176.  Tammy Siu will call back to the referent on that day and will assign a HOME worker to screen the client.  Between the hours of 4:30PM- 8AM, Monday to Friday, and all hours on weekends, staff can make a referral to the 24-hour TIES referral line at the San Mateo Health Dept at 1-800-675-8437.  The TIES worker will give the information to Tammy Siu at the next business day.    CASE MANAGEMENT We provide: v      Provide access to primary care provider and specialist v      Coordinate services, such as; Alcohol and Drug tx, Mental Health services, housing, food v      Monitor service delivery through regular follow up visits v      Provide health education and teach new coping skills v      Promote decrease of non acute emergency dept usage   ELIGIBILITY REQUIREMENTS: >7 visits @ County of San Mateo Medical Emergency Department in the last 12 months, age 18 and over, Medi-Cal, Uninsured, or underinsured, San Mateo County resident.   For additional information about HOME TEAM, please contact: Tammy Siu, MA, M.Ed.,MFTI Social Work Supervisor/HOME Team Lead Phone: 650-573-2180   Pager:  650-632-1176 Fax: 650-573-2310 tsiu@co.sanmateo.ca.us 225 37th Avenue, San Mateo, CA 94403