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Supporting Health and Personal Empowerment (SHAPE) in the Community

San Bernardino County, CA
Program Year: 2019

Abstract:
The SHAPE program provides patients who have complex care conditions with additional services in the Primary Care setting. Services include interventions for medical, social, behavioral health, functional impairment, and cultural and environmental factors affecting the health care choices available to patients. This program seeks to help patients reduce avoidable use of emergency care and inpatient hospitalizations. Each team consists of a Behavioral Health Clinician, RN Care manager, Clinical Assistant, and a Community Health Worker, who work with each other and clinic staff to address each patient's needs. Patients are considered to have high acuity if they have had one inpatient hospital stay or at least three emergency room visits in the past 16 months, are homeless, or have been diagnosed with at least three of the eligible chronic conditions. These are: COPD, diabetes, traumatic brain injury, congestive heart failure, coronary artery disease, chronic kidney disease, dementia, hypertension, asthma, major depressive disorder, bipolar disorder, and psychotic disorders. Due to the newness of the SHAPE Program, statistical data has yet to be compiled, however, the initial anecdotal data provided by patients and staff has been enough to gain support from the San Bernardino County Board of Supervisors for continuation of the program.

Contact:
Ms. Evelyn Samaniego
Secretary II