Our Model - Sacramento Covered

Our Model Of Work

We understand that the health care system is complex and many, especially the most high-need and medically complex patients, need a whole-person approach to care management.

Through a peer-driven, personalized, comprehensive care management approach, we address social determinants of health and reduce health disparities by connecting people to health coverage, primary care, mental and behavioral health care, housing, and other critical resources. We walk with our clients as they navigate the continuum of care and stand with them until they reach stability.

Patient-Centered

Coordinating care and services to meet unique needs of each person.

Field-Based

Supporting individuals with complex health issues get the care they need.

Data-driven

Improving care through cross-organizational coordination and collaboration among systems.

Patient-Centered

Our programs help clients achieve their overall health goals by delivering services that:

Improve quality outcomes.
Reduce health disparities.
Drive delivery system transformation and innovation through value-based initiatives.
Modernize systems and payment reforms to improve the lives of our clients and all those served through the healthcare system.

Field-Based

We provide intensive outreach and care coordination for people experiencing homelessness and/or have complex health and behavioral health issues. Our services include:

Addressing social determinants of health / Mitigating barriers
Linkage to insurance coverage, eligible programs and services
Facilitating connections & transitions between hospitals & community (Primary Care provider)
Linkage to full housing continuum
Co-management of clients with health & housing partners
Functional assessment & clinical oversight

Data-driven

Our population health data infrastructure supports our work to track the care and outcomes of our clients. This allows for data mining and analysis, reducing complexity and increasing flexibility to promote consistent and seamless data-sharing.

Outcome focused
Track, manage and report on all services provided
Full integration of all our programs
Quickly adapt care plans to meet immediate and long-term needs
Coordinate with other agencies to address client health and social needs
Reduce duplication of services
See the entire lifetime of a client's health journey

Learn More About Our Levels of Care

Patient-Centered

Field-Based

Data-driven