Patient-Centered Services

All of our programs are complementary, coordinated, and integrated to ensure individuals get the wraparound services they need, including medical, behavioral, dental, vision, specialty, and social services.

Meeting Clients Where They Are

Our Community Health Workers, Health Navigators and Patient Navigators provide culturally responsive, personalized assistance, working with clients to ensure their needs are at the center of our care and support. We meet people where they are and walk with them through the continuum of care to help them reach stability and self-sufficiency.

Improving Health Outcomes

0 Navigation Services

provided in 2020, including enrollment for Medi-Cal, Covered California and Calfresh, appointments for medical, dental, and behavioral health services, and help to find and change a primary care provider. Our Health Navigators are at clinics, schools, resource centers, career centers, public events, and reachable through our call center.

0 Individuals Served

in 2020 for health and homelessness. Our Community Health Workers met clients in encampments, on the streets, in shelters, at hospitals, and in clients' housing to provide intensive outreach and case management.

0% Reduction

in Emergency Department readmission rates. Our Patient Navigators are in Emergency Departments supporting patients with getting follow-up care, establishing a primary care home and connecting to resources.

0 Total Services Provided in 2020

Integration

Our Community Health Workers, Health Navigators, and Patient Navigators all work together to ensure clients receive a holistic, whole person care approach to the services they need.

Re-Entry Services

Our Community Cafe is by the Sacramento County Main Jail and is a welcoming place for individuals transitioning from incarceration to work with our Community Health Workers and Health Navigators to get connected to health coverage, health and behavioral health services, housing supports, and other resources.

Hospitals

Our partnering hospitals are:

Mercy General Hospital

Methodist Hospital

Mercy San Juan Hospital

Mercy Folsom Hospital

Sutter General Hospital

UC Davis Hospital

Access to Food

Since 2017, we have enrolled more than 1,000 individuals into CalFresh and provided nearly 600 referrals to local food resources.

During the first 10 weeks of the COVID-19 pandemic in 2020, we delivered more than 21,000 fresh meals to medically vulnerable individuals - both newly housed and homeless.

Transportation

In 2020, we scheduled more than 5,000 transportation services to help get clients to their medical, housing and other needed appointments.