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Learn more about our COVID-19 Response

Our Model Of Work

Health care is complex; so are the needs and experiences of Sacramento’s diverse populations. We help bridge the gap between systems and the community through a peer-driven, one-on-one approach to best respond to individual needs. We work to reduce health disparities and improve the overall well-being of the community by helping families and individuals connect to health coverage, primary care, mental and behavioral health care, housing, and other critical resources.

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

Our patient navigators provide patient-centered care coordination to help hospital patients establish a primary care home for all their health needs.

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

Fieldwork

We provide intensive care coordination for individuals experiencing homelessness and/or have complex health and behavioral health issues.

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

Learn More About Our Levels of Care