Healthy Community Forum for Sacramento Region dba Community HealthWorks

Homeless Health Services - Field-based Outreach, Care Coordination, and Housing Supports for the CalAIM Program: Community HealthWorks (CoHeWo)s Homeless Health Services provides personalized, case management, housing support and tenancy support to individuals experiencing homelessness. CoHeWos team of Community Health Workers (CHW) is one of the largest field-based teams in Sacramento County. Since 2017, CoHeWo 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. CoHeWo 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, CoHeWo 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. Since 2022, CoHeWo has deployed an impactful homeless street outreach program in coordination with Sacramento County DHSH serving the American River Parkway and Encampments throughout the unincorporated areas of Sacramento County. In 2023, CoHeWos street outreach team served 1,289 individuals, providing 32,020 services along with 320 CalAIM referrals, and 297 housing and shelter placements (94 permanent, 15 transitional, 188 shelters).In 2023, the CalAIM Enhanced Care Management and Community Supports team provided over 37,000 services to 1,952 individuals. Across all of the programs, CoHeWo generated 2,292 CalAIM referrals for clients in Sacramento County. Also, the Reentry team provided over 3,300 services to 860 individuals. CHWs and housing specialists facilitated 781 housing placements to permanent, transitional and shelter options in the local community.

Health Navigation Program: Community HealthWorks (CoHeWo) is the Sacramento regions leading health access and enrollment assistance organization dedicated to achieving health care access and coordination for all area residents. CoHeWos 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, Community HealthWorks expanded its navigation program to add a pediatric navigator program at Sutter Medical Center, Sacramento. In 2023, the Pediatric Navigation program served 3,782 newborn babies connecting their families to critical coverage and medical homes and scheduled their 2-day follow-up appointments. During 2023, Community HealthWorks CHWs on the health navigation team provided about 39,800 navigation services to approximately 9,900 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. 6,726 individuals were provided CalFresh services which include screening, education, enrollment and retention support.