Our Model - Sacramento Covered

Our Model Of Work

Health care is complex, and so are the needs and experiences of Sacramento’s diverse populations. Sacramento Covered bridges the gap between systems and the community by using a peer-driven, one-on-one approach to best respond to individual needs. We help families and individuals of all backgrounds connect to health coverage, primary care, mental and behavioral health care, housing, and other resources.

Community

Supporting the community by finding access to health, nutrition and social service programs and resources.

Hospitals

Supporting patients seeking primary care services.

Fieldwork

Providing support for individuals experiencing homelessness and complex health issues.

Community

Support for families and individuals who need help accessing health, nutrition and social service programs and resources. We work with residents over the phone and in-person in offices located throughout Sacramento County.

Outcome focused
Address social determinants of health (SDOH) / and other barriers
Linkage to insurance coverage, eligible programs and services

Hospitals

To support patients visiting the emergency department for primary care reasons, our patient navigators provide patient-centered care coordination, including helping patients establish a medical home for all their health needs.

Outcome focused
Address social determinants of health (SDOH) / Mitigate barriers
Linkage to insurance coverage, eligible programs and services
Facilitate linkages & transitions between hospitals & community (Pimary care provider)

Fieldwork

Community care management is the work we do to improve health and housing outcomes through intensive care coordination for individuals experiencing homelessness and who also have complex health/behavioral health issues.

Outcome focused
Address social determinants of health (SDOH) / Mitigate barriers
Linkage to insurance coverage, eligible programs and services
Facilitate linkages & transitions between hospitals & community (Pimary care provider)
Facilitate linkages & transitions between levels of care
Linkage to full housing continuum
Co-management of clients with health & housing partners
Functional assessment & clinical oversight

Learn More About Our Levels of Care

Community

Hospitals

Fieldwork