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      <Desc>Homelessness Services - Pathways to Health &amp; Homes Outreach, Care and Housing Coordination, and Health Homes Program:Pathways to Health and Home is a statewide initiative led 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. As a partner of the program, Sacramento Covered Community Health Workers provide intensive outreach engagement and care coordination services to ensure that enrollees within the program receive the wrap-around services they need for ongoing care that supports stability. Our diverse team of health workers build trust and rapport with individuals experiencing, or at risk of experiencing, homelessness, connect them to primary health and behavioral health services, alleviate barriers to care (like transportation), 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.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.In 2019, Sacramento Covered community health workers provided over 70,000 services to over 2,300 individuals.</Desc>
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        <Desc>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. Our health navigators represent the remarkable diversity of our region as they provide in-person, culturally-competent 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 healthcare options; enroll for 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 partners to provide residents in urban and rural communities with information to health care and nutrition programs. Our navigators provide services at hundreds of key events, including workshops, cultural festivals, health and resource fairs, and faith-based events.In 2019, Sacramento Covered health navigators provided over 41,000 navigation services to approximately 9,000 individuals, including in-person health coverage enrollment assistance, renewal/re-determination assistance, and retention of health coverage. They also offered healthcare 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.</Desc>
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        <Desc>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 connect to a "medical home." It began in late 2013 when Dignity Health selected Sacramento Covered to expand the Patient Navigator program to work together towards reducing ED readmission rates among uninsured and underinsured individuals. In 2014, Sacramento Covered launched this program in partnership with UC Davis Health System. Through the Patient Navigator program, we have at least one full-time Patient Navigator in each hospital emergency department to build rapport with patients, help access primary care services, identify community resources, and provide education about appropriate health care utilization and self-care. Our 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. In 2019, Sacramento Covered patient navigators provided over 35,000 services to over 12,000 patients, who were seen in emergency departments for non-urgent, primary care reasons.</Desc>
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