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Health Care Navigator Project

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Anira Khlok

on 27 February 2015

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Transcript of Health Care Navigator Project

Measurable Outcomes
Pathways Referral & Admit Process
Community Impact
The goals of the Homeless Healthcare Navigator Project is to improve the health and wellness of homeless individuals residing in Sacramento by:
increasing access to health and mental health services
decreasing homelessness
increasing housing
decreasing hospital stays
decreasing mental health crises
decreasing Hospital ED incidents
decreasing incarceration

design by Dóri Sirály for Prezi
Partners Involved
The PD or CD receives a call/email with referral information. PD or CD does a brief assessment with the referring party to determine if individual/family meets criteria.
Sub-population Characteristics
Homeless adults suffering from mental illness
Chronically homeless
Homeless individuals with children
Frequent users of the emergency response system
Transition Aged Youth

Downtown Sacramento Partnership Navigator Program Stats
Survey Sample, 2950 homeless individuals
Males: 73.45%, Females: 26.50%
Average Age: 46.7 years old, servicing all ages
Total people assisted year to date 197
Total Housed: 21 individuals, 6 unsuccessful housing cases- 71% effectiveness
Defining the Collaborative
2-1-1 Sacramento
Downtown Sacramento
TLCS, Inc.
Genesis Mental Health
Provides street outreach workers or "Health Navigators," that will link homeless individuals to health appointments at local clinics with the technical assistance of Community Link 211.
Navigators have existing relationships with homeless individuals who frequent the Downtown Area.
Navigators will work in coalition with Genesis Mental Health Outreach Worker and Case Manager at Transitional Living and Community Support, Inc. to ensure that clients have access to supportive services.

Deliverable Resources
# of clients referred to collaborative partners
In an environment of acceptance, compassion, and respect, the team at Genesis Mental Health provides free mental health services to the poor and homeless. We welcome anyone in need of our services with no qualifications to entry, including those who do not meet the target population criteria for County Mental Health.

Genesis dedicates a Master's-level mental health counselor to meet with homeless individuals in their environment, providing:
On the street mental health assessment.
On the street counseling.
On the street professional referrals.
Genesis Mental Health Counselor will with work with DSP Health Navigator to assist individuals that are not accessing services.
Genesis will also work with TLCS Inc. Case Manager to provide services for those individuals who do not meet the target for accessing County mental health services.

Deliverable Resources
# of guests received mental health counseling
# of guests referred to Genesis for mental health services
TLCS, Inc. provides a variety of case management and supported housing services to over 1200 clients per year. TLCS, Inc. is a Full Service Partner with the Sacramento County Mental Health System (MHSA).

A dedicated Outreach Case Manager will work in concert with DSP Health Navigators and Genesis Outreach Worker to:
Foster Engagement
Conduct assessments to determine "serious and persistent psychiatric disability".
Connect appropriate clients with Guest House to enter the "front door" of the Sacramento County Mental Health System.
Clients who are connected will receive assistance in obtaining ongoing mental health services, supportive housing and other resources to encourage successful community living.
Provide information and referral services to project participants, 24 hours per day, 7 days per week.
Facilitate real-time referrals and appointment scheduling.
Populate client database to track client referrals and monitor access.
Assess project to inform protocols for central intake throughout the homeless service continuum.
Train discharge planners on availability and use of 2-1-1

Deliverable Resources
# of clients receiving service referrals.
% of clients utilizing referrals.
External Partnerships
We will work with X hospital to xyz.
External Collaboration
SSF & Coordinated Entry
Local Clinics & Primary Care Centers
Engaging with Public Entities and In-Kind Partners
# of Client contacts
# of Clients connected with Guest House services
# of Clients successfully housed
The mechanism for sharing and measuring outcomes will stem from The Downtown Sacramento Foundation's existing database. This database will provide the following:
Enable the administrator to create individualized intake forms
Record and route client information to a particular service agency
Enable navigators remote access via a tablet
Generate statistics and provide client service history

The collaborative will aim to engage with hospitals through the following:
Conducting quarterly meetings to discuss emergency response trends juxtaposed with Downtown Sacramento Foundation's Point-In-Time Counts and analyzing baseline stats
Identifying trends and finding solutions
Creating linkages between the Hospital and 2-1-1 to resource inward and outward
Providing supplemental training for discharge planners to utilize 2-1-1 service

WellSpace Health will serve as the initial source for primary care health services. Their clinic, located at 7th and H Streets will become the "medical home" for clients who are currently unlinked.
As this project progresses, linkages with clinics and primary care centers will continue to grow enabling the project to serve more individuals overtime
This partnership will request that clinics and primary care centers designate a number of appointment times for clients of this project
Sacramento Steps Forward's Healthcare Committee will continue to provide coordination, oversight, and additional support to ensure the longevity and success of this program. Additionally, this pilot project will aid in the development of the Continuum of Care's own Coordinated Entry.
This program will sustain itself by accessing alternate funding sources including businesses, hospitals, and Mental Health Services Act (MHSA) county funds. Sustainability will require involving key stakeholders and informing them of the positive impacts of this program. Once a successful program is developed, we will seek to expand geographically.
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