Healthy Community Forum For The Greater Sacramento Region

HEALTHY COMMUNITY FORUM FOR THE GREATER SACRAMENTO REGION OPERATES UNDER THE NAME SACRAMENTO COVERED, A NOT-FOR-PROFIT, COMMUNITY-BASED ORGANIZATION DEDICATED TO IMPROVING THE OVERALL HEALTH OF AREA RESIDENTS BY CONNECTING THEM TO MEDICAL COVERAGE, PRIMARY AND PREVENTATIVE CARE. THROUGH INNOVATIVE PARTNERSHIPS, AS WELL AS OUTREACH AND ENROLLMENT SERVICES, SACRAMENTO COVERED HEALTH NAVIGATORS CONNECT RESIDENTS OF ALL SOCIOECONOMIC AND ETHNIC BACKGROUNDS TO NEEDED HEALTHCARE SERVICES AND OTHER RESOURCES IN ORDER TO INCREASE UNDERSTANDING OF THE HEALTH CARE DELIVERY SYSTEM, MITIGATE BARRIERS TO CARE AND IMPROVE HEALTH OUTCOMES.

HOMELESS HEALTH SERVICES - FIELD-BASED OUTREACH, CARE COORDINATION, AND HOUSING SUPPORTS FOR THE PATHWAYS TO HEALTH + HOME PROGRAM AND HEALTH HOMES PROGRAM:SACRAMENTO COVEREDS (SC) HOMELESS HEALTH SERVICES PROVIDES PERSONALIZED SUPPORT AND CASE MANAGEMENT TO INDIVIDUALS EXPERIENCING HOMELESSNESS AND/OR HAVE COMPLEX HEALTH ISSUES. SCS TEAM OF COMMUNITY HEALTH WORKERS (CHW) IS ONE OF THE LARGEST FIELD-BASED TEAMS IN SACRAMENTO COUNTY TO ENSURE HEALTH AND HOUSING STABILITY. SC LEADS THE PATHWAYS TO HEALTH AND HOME (P2HH) PROGRAM A STATEWIDE WHOLE PERSON CARE INITIATIVE STEERED BY THE CITY OF SACRAMENTO TO IMPROVE THE HEALTH, QUALITY OF LIFE, AND HOUSING STABILITY OF INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS. THE INITIATIVE SEEKS TO ALIGN SYSTEMS FOR THE PROVISION OF MEDICAL, BEHAVIORAL HEALTH, AND SOCIAL SERVICES TO BUILD A COMPREHENSIVE AND INTEGRATED SYSTEM OF CARE. THE PROGRAM STARTED AS A SMALL OUTREACH PILOT PROJECT DURING THE MID-YEAR OF 2017. IN NOVEMBER 2017, THE PILOT PROJECT EVOLVED AND GREW TO A 4-MONTH PROJECT, WHICH FINALLY REACHED FULL LAUNCH IN MAY OF 2018. SINCE THE PROGRAM STARTED IN LATE 2017, SACRAMENTO COVERED HAS SUCCESSFULLY ENROLLED INDIVIDUALS EXPERIENCING HOMELESSNESS INTO THE PATHWAYS TO HEALTH AND HOME PROGRAM - CONNECTING THEM TO PRIMARY AND PREVENTATIVE CARE, MENTAL HEALTH AND BEHAVIORAL TREATMENT SERVICES, HOUSING AND OTHER NEEDED RESOURCES. IN 2019, SACRAMENTO COVERED EXPANDED ITS SERVICES BY WORKING WITH MEDI-CAL HEALTH PLANS, SUCH AS MOLINA HEALTHCARE OF CALIFORNIA, TO PROVIDE WRAP-AROUND CARE COORDINATION SERVICES TO THEIR MEMBERS.SC ALSO PROVIDES CARE MANAGEMENT FOR THE DEPARTMENT OF HEALTH CARE SERVICES HEALTH HOMES PROGRAM (HHP), ASSISTING MEDI-CAL MANAGED-CARE MEMBERS SUFFERING FROM CHRONIC HEALTH CONDITIONS AND/OR HOMELESSNESS TO OBTAIN HEALTH CARE, SOCIAL SERVICES, AND HOUSING SUPPORT. AS THE LEADING PARTNER OF HHP AND P2HH, SC CHWS PROVIDE INTENSIVE OUTREACH ENGAGEMENT, BUILD TRUST AND RAPPORT WITH INDIVIDUALS WITHIN THE PROGRAMS, ALLEVIATE BARRIERS TO CARE (INCLUDING TRANSPORTATION AND FOOD), AND PROVIDE ADVOCACY AND THOROUGH FOLLOW-UP. THEY SERVE IN VARIOUS ENVIRONMENTS (INCLUDING HOMELESS ENCAMPMENTS, STREET OUTREACH, HOME VISITS, AND SHELTERS) AND WORK CLOSELY IN COLLABORATION WITH HEALTH PLANS, PRIMARY CARE CLINICS, BEHAVIORAL HEALTH CLINICS AND PROGRAMS, HOUSING AGENCIES, LAW ENFORCEMENT AND OTHER SERVICES FOR CUSTOMIZED CARE THAT ENSURES HEALTH AND SOCIAL DETERMINANTS OF HEALTH ARE MET.DURING 2021, SACRAMENTO COVERED'S COMMUNITY HEALTH WORKERS PROVIDED OVER 88,5750 SERVICES TO OVER 2,369 INDIVIDUALS.

HEALTH NAVIGATION:FOR THE LAST 20 YEARS, SACRAMENTO COVERED HAS BEEN WORKING ON IMPROVING THE OVERALL HEALTH OF RESIDENTS IN THE SACRAMENTO REGION BY CONNECTING THEM TO MEDICAL COVERAGE, PRIMARY AND PREVENTATIVE CARE, AND OTHER NEEDED RESOURCES. SC HEALTH NAVIGATORS REPRESENT THE REMARKABLE DIVERSITY OF THE SACRAMENTO REGION AS THEY PROVIDE IN-PERSON, CULTURALLY-RESPONSIVE ASSISTANCE TO FAMILIES AND INDIVIDUALS ACROSS FIVE COUNTIES, 15 NEIGHBORHOODS AND IN 13 DIFFERENT LANGUAGES. AS TRUSTED COMMUNITY HEALTH ADVOCATES, HEALTH NAVIGATORS HELP RESIDENTS UNDERSTAND THEIR HEALTH CARE OPTIONS; ENROLL IN AFFORDABLE HEALTH, DENTAL, AND NUTRITION COVERAGE; FIND A DOCTOR AND SCHEDULE THEIR DOCTOR APPOINTMENTS; MITIGATE SPECIFIC BARRIERS TO CARE LIKE ARRANGING TRANSPORTATION AND LANGUAGE INTERPRETATION; CONNECT TO OTHER NEEDED SERVICES; AND UNDERSTAND HOW TO ACCESS A MULTITUDE OF ADDITIONAL RESOURCES IN THE AREA. IN 2019, SACRAMENTO COVERED EXPANDED ITS NAVIGATION PROGRAM TO ADD A PEDIATRIC NAVIGATOR PROGRAM AT SUTTER MEDICAL CENTER, SACRAMENTO. AS BOTH A PARTNER AND HOST OF COMMUNITY EVENTS THROUGHOUT THE AREA, SACRAMENTO COVERED WORKS WITH AN ARRAY OF COMMUNITY PARTNERS TO PROVIDE RESIDENTS IN URBAN AND RURAL COMMUNITIES WITH INFORMATION AND HEALTH NAVIGATION FOR HEALTH AND NUTRITION PROGRAMS. SC HEALTH NAVIGATORS PROVIDE SERVICES AT HUNDREDS OF KEY EVENTS, INCLUDING WORKSHOPS, CULTURAL FESTIVALS, HEALTH AND RESOURCE FAIRS, AND FAITH-BASED EVENTS.DURING 2021, SACRAMENTO COVERED'S HEALTH NAVIGATORS PROVIDED OVER 63,000 NAVIGATION SERVICES TO APPROXIMATELY 9,800 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, SUCH AS CALFRESH AND CALWORKS ENROLLMENT.

PATIENT NAVIGATION PROGRAM:THE PATIENT NAVIGATOR PROGRAM IS A UNIQUE COLLABORATION WITH DIGNITY HEALTH AND UC DAVIS HEALTH SYSTEM TO WORK WITH PATIENTS VISITING THE EMERGENCY DEPARTMENT (ED) FOR PRIMARY CARE REASONS AND HELP THEM ESTABLISH A "MEDICAL HOME." THE PROGRAM BEGAN IN LATE 2013 WHEN DIGNITY HEALTH SELECTED SACRAMENTO COVERED TO EXPAND THE PATIENT NAVIGATOR PROGRAM TO REDUCE ED READMISSION RATES AMONG UNINSURED AND UNDER INSURED INDIVIDUALS. IN 2014, SACRAMENTO COVERED LAUNCHED THIS PROGRAM IN PARTNERSHIP WITH UC DAVIS HEALTH SYSTEM. THROUGH THE PATIENT NAVIGATOR PROGRAM, SC HAS AT LEAST ONE FULL-TIME PATIENT NAVIGATOR IN EACH HOSPITAL EMERGENCY DEPARTMENT TO BUILD RAPPORT WITH PATIENTS, HELP THEM ACCESS PRIMARY CARE SERVICES, IDENTIFY COMMUNITY RESOURCES, AND PROVIDE EDUCATION ABOUT APPROPRIATE HEALTH CARE UTILIZATION AND SELF-CARE. SC PATIENT NAVIGATORS PROVIDE THOROUGH FOLLOW-UP WITH EACH PATIENT AND WORK CLOSELY WITH HEALTH PLANS, PRIMARY CARE PHYSICIANS, SPECIALISTS, NURSES AND CLINICS TO HELP COORDINATE CARE. DURING 2021, SACRAMENTO COVERED'S PATIENT NAVIGATORS PROVIDED OVER 46,156 SERVICES TO OVER 10,193 PATIENTS, WHO WERE SEEN IN EMERGENCY DEPARTMENTS FOR NON-URGENT, PRIMARY CARE REASONS.