Community HealthWo

Homeless Health Services - Field-based Outreach, Care Coordination, and Housing Supports for the CalAIM Program: Sacramento Covered's (SC) Homeless Health Services provides personalized, case management, housing support and tenancy support to individuals experiencing homelessness. SC's team of Community Health Workers (CHW) is one of the largest field-based teams in Sacramento County. Since 2017, SC has provided outreach and engagement, data management, and robust housing navigation and tenancy support services to participants in Pathways to Health + Home (Pathways), the City of Sacramentos Whole Person Care Pilot. SC was also the only community-based organization certified to serve as a Community-Based Care Management Entity (CBCME) by the health plans in Sacramento County as part of their Health Homes Program between 2019 through 2021. Additionally, SC is contracted with all the Sacramento County health plans as an Enhanced Care Management and Housing Community Supports provider through the Department of Health Care Services CalAIM program. In 2022, Sacramento Covered also started a new street outreach team serving the American River Parkway and Encampments throughout the unincorporated areas of Sacramento County.During 2022, Sacramento Covered's community health workers provided over 41,800 services to 3,300 individuals. Additionally as a CalAIM Enhanced Care Management (ECM) and Community Supports (CS) provider, in 2022 Sacramento Covered served 1,823 unduplicated members, which predominantly consists of individuals experiencing homelessness. Over 171 individuals were screened for connection to medical and behavioral health services, housing support, and other basic needs in the Adult Reentry Program working closely with Sacramento County Adult Correctional Health. CHWs and housing specialists facilitated 374 housing placements to permanent, transitional and shelter options in the local community.

Patient Navigation Program: The Patient Navigation program is a unique partnership with local hospital systems (Dignity Health, Kaiser Permanente, UC Davis) to connect with patients visiting the Emergency Departments (ED) with Community Health Workers (CHWs) to address social determinants of health and navigate their healthcare system to achieve better health outcomes. Sacramento Covered manages a team of CHWs stationed in six local Emergency Departments (ED) throughout Sacramento County. ED CHWs are proven to be effective for ensuring lower-income, uninsured individuals are receiving Medi-Cal enrollment supports, navigation services for primary care, and long-term linkages to a health home. In 2022, Sacramento Covered's CHWs under the Patient Navigation program provided over 52,200 services to approximately 9,500 patients, who were seen in emergency departments for non-urgent, primary care reasons. 54% of patients served by Emergency Department, CHWs received assistance with follow-up appointments after hospital discharge.

Health Navigation Program: Sacramento Covered (SC) is the Sacramento regions leading health access and enrollment assistance organization dedicated to achieving health care access and coordination for all area residents. Sacramento Covereds diverse team of Community Health Workers on the Health Navigation team are embedded in community settings throughout the Greater Sacramento Region and provide health sustaining supportive services to address social determinants of health which include, but not limited to: health coverage enrollment (new applications renewals, reporting changes); Medi-Cal intercounty transfers, plan selection or changes to assigned provider/health plan; CalFresh application; primary, dental or vision care appointments; transportation services; interpreting services; education on health coverage and nutrition programs; cell phone and identification provision; as well as facilitating referrals to other critical resources such as WIC, legal services, in-home supportive services (IHSS) and child care. In 2019, Sacramento Covered expanded its navigation program to add a pediatric navigator program at Sutter Medical Center, Sacramento. In 2022, the Pediatric Navigation program served 2,766 newborn babies connecting their families to critical coverage and medical homes and 98% of babies served were scheduled for their 2-day follow-up appointments. During 2022, Sacramento Covered's CHWs on the health navigation team provided about 41,500 navigation services to approximately 10,600 individuals, including in-person health coverage enrollment assistance, renewal/re-determination assistance, and retention of health coverage. They also offered health care education, outreach, troubleshooting assistance, and care coordination related to finding or changing a doctor, scheduling doctor appointments, and arranging transportation, language interpretation, and other requested services. 3,546 individuals were screened for CalFresh eligibility, and 2,900 individuals were provided CalFresh education, enrollment and retention support. CHWs continued to assist those impacted by COVID-19 through education, prevention, and mitigating services, reaching 4,821 people.