Community & Homeless Health Programs

Homeless Prevention

The best way to address homelessness is to prevent it from occurring in the first place. Services can include diversion and immediate crisis resolution.

By supporting community members to address other social needs such as food security, health and energy access, we can position individuals to optimize their resources to maintain their housing. Current partnerships include:

The Utility Reform Network (TURN), Statewide

The Housing & Energy Action Leadership (HEAL) Program is a unique partnership between TURN and CommonSpirit Health designed to promote utility programs and policies that prevent homelessness through three primary mechanisms: 1) training and education for health care staff and community partners; 2) expansion of consumer hotlines and tools; and 3) collaborative policy and advocacy work. As a part of this effort, we've co-developed trainings to expand the knowledge of our staff to better support individuals who are energy insecure.

Legal Services of Northern California (LSNC), Sacramento, CA

The Medical Legal Partnership (MLP) program will identify health-harming legal needs and address social determinants of health to improve the health outcomes of Dignity Health’s patient populations, particularly individuals who are at risk of or currently experiencing homelessness. Examples of health-harming legal needs include but are not limited to: barriers with housing/housing subsidies, substandard housing conditions, evictions and utility shut-offs, discontinuation of entitled public benefits, and denials of health care coverage benefits. The program currently operates out of Methodist Hospital of Sacramento, Mercy General Hospital of Sacramento and Mercy Family Health Center.

Transitions of Care and Coordination

Persons experiencing homelessness (PEH) often suffer from chronic conditions and comorbidities; as a result, their health can be especially fragile post-hospitalization. It is important to create spaces where unsheltered PEH can rest and recover after a hospital stay. Further, we need to connect individuals to outreach services while they are in our care to ensure they don’t fall through the cracks of the continuum of care. Transitions of care and care coordination programs can include but are not limited to: Medical respite and mobile outreach.

Medical Respite/Recuperative Care

The best way to address homelessness is to prevent it from occurring in the first place. Services can include diversion and immediate crisis resolution.

By supporting community members to address other social needs such as food security, health and energy access, we can position individuals to optimize their resources to maintain their housing. Current partnerships include:

The Utility Reform Network (TURN), Statewide

The Housing & Energy Action Leadership (HEAL) Program is a unique partnership between TURN and CommonSpirit Health designed to promote utility programs and policies that prevent homelessness through three primary mechanisms: 1) training and education for health care staff and community partners; 2) expansion of consumer hotlines and tools; and 3) collaborative policy and advocacy work. As a part of this effort, we've co-developed trainings to expand the knowledge of our staff to better support individuals who are energy insecure.

Legal Services of Northern California (LSNC), Sacramento, CA

The Medical Legal Partnership (MLP) program will identify health-harming legal needs and address social determinants of health to improve the health outcomes of Dignity Health’s patient populations, particularly individuals who are at risk of or currently experiencing homelessness. Examples of health-harming legal needs include but are not limited to: barriers with housing/housing subsidies, substandard housing conditions, evictions and utility shut-offs, discontinuation of entitled public benefits, and denials of health care coverage benefits. The program currently operates out of Methodist Hospital of Sacramento, Mercy General Hospital of Sacramento and Mercy Family Health Center.

Community and Mobile Outreach

The Salvation Army Mobile Outreach Programs, Central Coast, Merced, San Bernardino, San Joaquin, CA

The Salvation Army provides basic needs and case management services from a fully outfitted mobile outreach unit, literally meeting people where they’re at. Case managers focus on building upon the strengths of individuals and families to help them meet their housing goals while addressing key needs like access to healthcare. Case managers work with community partners, landlords, police departments and healthcare systems to address needs of the whole person.

Multi-disciplinary Care Coordination

The Frequent Users System Engagement (FUSE) Program, Los Angeles, CA

FUSE provides patients who are chronically homeless, assessed at California Hospital Medical Center, and who meet the eligibility requirements, with community-based case management to primary and behavioral health care and other needed resources & referrals provided by John Wesley Community Health (JWCH). FUSE provides eligible patients with housing navigation, through a partnership with Housing Works, initially to temporary housing, and then to permanent supportive housing. The goal of the program is to improve the health of patients who are chronically homeless, who meet the criteria as belonging in the 10th Decile, and increase their housing stability, and reduce their avoidable ED visits.

Social Work Emergency Department (ED) Program, Statewide

Hospital EDs need dedicated social work staff with the knowledge and relationships that will enable them to provide a warm hand-off to the community services each individual needs most. These dedicated social work staff improve the coordination of hospital and community resources for the homeless, and help fulfill our mission of addressing the root causes of poor health by caring and advocating for the most vulnerable. These social workers are trained in trauma-informed care protocols to ensure that their interactions with un-housed patients are trauma-informed and productive. ED social workers help develop individualized care plans with patients experiencing homelessness, based on the patient’s indicated priorities, and provide short-term case management and warm hand-offs to primary care, housing, behavioral health and addiction treatment services, benefits counseling, legal aid, and other resources as needed. This support is designed to reduce fragmentation and other barriers to care. Each ED social worker develops partnerships with the appropriate community organizations and government agencies, to build close linkages that ensure referrals result in access to services.

Larkin Street Youth Services and 3rd Street Youth Center and Clinic, San Francisco, CA

Young people participating in Rising Up benefit through one of two program components: 1) Rapid Rehousing - a housing model that offers up to 3 years of rent subsidy with intensive case management support; or 2) Problem Solving which is short-term support to prevent entry into homelessness all together. There has always been a need for behavioral health services for youth experiencing homeless. Following the pandemic, youth homeless providers recognized an increased need for behavioral health services for youth entering their doors. Our partnership has helped increase their behavioral health capacity by 1.5 FTEs. Further, 3rd Street Youth will also provide Mental Health First Aid training to community partners to better support youth during crisis and direct them to appropriate resources.

Housing Solutions

Housing is the key to ending homelessness. A community should have different housing options available for persons experiencing homelessness as each individual has a different level of need and comfort when it comes to accessing housing programs. One size [of housing] does not fit all and therefore we need to right-size our solutions to meet this need. HHI is keen on supporting communities with creating housing throughput, which means supporting the creation of different types of shelter and housing.

Permanent Housing Solutions

Stocktonians Taking Action to Neutralize Drugs (STAND), Stockton, CA

STAND is developing seven units of housing for the homeless in San Joaquin County. Four units will be built from the ground up on a lot which STAND owns. The additional three units are homes that were purchased and rehabilitated. Clients will either be homeless families or individuals. Some homes will be occupied by families and some units will be shared housing for individuals. The Housing Authority of San Joaquin will provide a mixture of Tenant-Based Vouchers and Project-Based Vouchers depending on if the clients are families or individuals.

East Beamer Way, Woodland, CA

East Beamer Way residences is a development of one and two-bedroom micro-duplexes that house at least 75 individuals who are unhoused, unstably housed or otherwise challenged in meeting market rate rental costs. Half the units will serve those with chronic mental illness with services provided by the Yolo County Health and Human Services Agency. The remaining residents, with less severe health and behavioral health issues, will receive ongoing case management services from two partner nonprofits, Fourth and Hope and Woodland Opportunity Village. Each fully equipped modular house will meet federal and state housing standards. These housing units will be located on a housing campus which also includes a shelter and Medi-Cal certified adult substance abuse residential treatment center.

Flexible Housing Subsidy Pool, San Francisco, CA

The Flexible Housing Subsidy Pool (FHSP) is a supportive housing program that provides housing location services, ongoing rental assistance, housing retention support, social services and rental subsidy administration to ensure long-term stability for individuals who have experienced homelessness. This program is a collective impact partnership between multiple City & County departments, Brilliant Corners, hospitals and other health care organizations, and other organizations engaged in serving individuals experiencing homelessness.

Interim Housing/Transitional

Dignity Moves, San Francisco, CA

In San Francisco, Dignity Moves and the City of San Francisco, with the support of Tipping Point Community, Urban Alchemy and Home First Services have partnered to develop an Interim Supportive Housing pilot project. This project will replace an existing safe sleeping site containing 44 tents with 70 individual prefabricated units that will provide privacy and security for the residents.The site is two parking lots at 33 Gough Street, leased by the City of San Francisco. There will be case management offices, a clinic, two dining rooms, restroom and shower facilities, laundry facilities and outdoor spaces with furniture and gardens. The residential furniture has been donated by Living Spaces and we are in discussions with Ikea, Room and Board and Home Depot for office, dining and outdoor furniture. There will be Wi-Fi, bicycle racks, planting and pet spaces as well. Local artists have signed on to create murals for the site. The site has been thoughtfully designed by the architectural firm Gensler to create a welcoming community and foster a sense of belonging.

Emergency Housing

Bakersfield Homeless Center (BHC), Bakersfield, CA

BHC is partnering with Dignity Health and Unite Us to improve transitions of care for people experiencing homelessness who are being discharged from local hospitals. BHC now accepts referrals for emergency shelter beds from hospitals through Connected Community Network to provide services to those who are being discharged. Seven staff are now trained to accept and process referrals; they are active users of the system. As calls are received from discharging staff or hospital case managers, BHC provides discharged patients with beds, based upon availability. To receive services, they must be able to care for themselves, pass a background screening and not previously have been expelled from the shelter.

System Transformation

In addition to providing direct services and capital, we recognize the need to invest in system transformation that leads to sustainable changes in how we respond to housing insecurities and homelessness. This work requires long-term commitment and active engagement across sectors to transform our homeless continuums of care while also addressing historic and ongoing structural inequities.

Current Partnerships

Community Solutions/Institute for Health Care Improvement (IHI), National

The Institute for Healthcare Improvement and Community Solutions, in partnership with Kaiser Permanente, Common Spirit, Providence St. Joseph’s and five Built-for-Zero communities are working on a two year pilot initiative to understand the most meaningful, measurable and transformative contribution health care can make to ending chronic homelessness. The goal of the project is that by the end of the two-year pilot initiative, participating pilot sites will have made measurable progress toward ending chronic homelessness, with a focus on building racially equitable systems.

Community Solutions’ Built for Zero initiative operates in nine regions with CommonSpirit facilities: Phoenix, AZ; Tucson, AZ; Sacramento, CA; Santa Cruz, CA; Bakersfield, CA; Nevada County, CA; Placer County, CA; Fremont County, CO, and Chattanooga, TN.

Funders Together to End Homelessness, National

In partnership with Funders Together to End Homelessness ( FTEH), the Health System Funders for Housing Justice was created to: 1) Map out and prioritize opportunities for health systems to have an impact on the homelessness system at state and national levels; 2) Create an action agenda for the network that includes investment opportunities, advocacy and policy priorities, and partnership recommendations; and 3) Build trust and a structure among participants for sustained collaboration after Funders Together’s facilitation formally ends. The network over the first few months of 2022 will be engaging in conversations around where they might come together around their main focus areas of medical respite and medical legal partnerships. FTEH will also be exploring opportunities to engage not only health systems, but private funders around this work.

System Transformation Work Completed To-Date

CommonSpirit Homelessness Assessment: In 2020-2021, CommonSpirit Health and Desert Vista Consulting administered a survey across all 142 CommonSpirit facilities nationwide to understand the status and array of homeless services provided across our footprint. The survey sought to identify best and promising practices for addressing the needs of the population experiencing homelessness, including transitions of care, care coordination, clinical-community linkages, and cross-sector information sharing. The assessment used a two-step data collection strategy: 1) Electronic survey fielded to the universe of CommonSpirit facilities; and 2) Virtual focus group interviews with facilities with identified practices and programs for their patients experiencing homelessness.

The full report can be found here.

Capacity-Building for Medical Respite Care Programs in California in Response to COVID-19: Four Case Studies- HHI in partnership with the National Institute for Medical Respite (NIMRC), operated by the National Health Care for the Homeless Council (NHCHC), produced a case study on four distinctive medical respite programs across California. The case study seeks to understand how medical respite programs were impacted by the COVID-19 pandemic and how these programs are building their capacity to serve patients who are well enough to be discharged but not well enough to return to the streets or shelter. Before exploring these research questions, the case studies highlight each program at baseline before the pandemic.

The case study can be found here.

Addressing Rural Communities and Homelessness (ARCH)- Through a partnership with Health Leads and guided by a Research Advisory Board, we conducted a mixed methods research project to learn about the lived experience of those managing housing insecurity and/or homelessness in rural California communities during COVID-19. The sampling strategy worked to overrepresent the voices of the BIPOC population as part of the project’s commitment to pursue the project in accordance with defined Racial Health Equity principles. The project focused inquiries in 3 counties (Shasta, Tulare, and rural communities in San Bernardino) which were selected with the assistance of the Research Advisory Board through a consensus making decision process. Community informed and field tested survey and focus group question banks were created to reach more than 300 individuals in our counties of focus.

Read more about our research findings here.

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