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Field-Based Approach

Moving People Toward Health and Stability.

As one of the largest field-based outreach teams in the region, our Community Health Workers provide intensive outreach and care coordination to individuals experiencing homelessness and/or have complex health issues and connect them to comprehensive health and social care.

Case Management

In our implementation of the Whole Person Care and Health Homes pilot programs, we made incredible strides in building trust and rapport with each client, ensuring they receive integrated physical, behavioral, and social services based on their goals, needs and preferences. 

We continue to provide these supportive case management services to address medical and nonmedical needs and are committed to establishing strong relationships with clients, their care team, and our partner agencies. We work with numerous health care, housing, and social service providers to continue to grow a patient-centered continuum of care.

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provided by our team for City of Sacramento's Whole Person Care program since its launch in 2017.

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by our team for Health Homes program since its beginning in 2019.

Between 2018 and 2020, our Community Health Workers facilitated 1,055 housing placements for individuals experiencing homelessness.

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Whole Person Care

As the leading partner of the City of Sacramento's four-year Whole Person Care initiative, we built, managed and progressed the pathways for clients experiencing homelessness.

We led outreach and engagement, program enrollment and eligibility, care management, and data management and analytics. 

Click here to learn more from the program evaluation report.

A Trusted Team

The best care is achieved through relationships. Our diverse team of Community Health Workers, Health Navigators, and Patient Navigators represent the communities we serve and are compassionate, resilient, and assertive. 

From the hospital to the homeless shelter, from the health center to the housing authority, they meet clients where they are. They receive ongoing training to recognize the barriers that prevent people from accessing care and help pave a smoother path toward improved health.



Transitional Housing

We own and operate a behavioral health recuperative care home, where we provide housing and case management to six residents at a time. This transitional house serves those most vulnerable who are experiencing homelessness, have behavioral health needs and frequent emergency department visits.

We offer our clients:

A safe place to stay while they recover from their health crisis.

A treatment plan that is customized to their unique needs.

Services in English, Spanish and other languages.

Community Transition

Our adult reentry services supports individuals who were formerly incarcerated with help to return to the community successfully. We coordinate services with local health and justice system providers to provide health coverage enrollment and access to health care, behavioral health care, and social services.