Pathways to
Health + Home

Pathways to Health + Home (Pathways) — the City of Sacramento’s Whole Person Care program — is a fouryear pilot to improve the health, quality of life, and housing stability for the City’s most vulnerable individuals experiencing, or at-risk of experiencing, homelessness. Led by the City, the program brings together local hospitals, community clinics, health plans, homeless services and housing providers, first responders, and community-based organizations to create an integrated system of care. The program is the cornerstone of the City’s commitment to housing 2,000 homeless individuals by 2020.

Pathways targets Sacramento’s most vulnerable individuals experiencing, or at-risk of experiencing, homelessness. The program supports individuals who not only have the highest service needs, but also the highest utilization and costs associated with ambulance rides, fire and police department encounters, health emergencies, and hospitalizations. To be eligible for the program, individuals must be eligible or enrolled in Medi-Cal and meet the following health and crisis system utilization criteria:

• One or more inpatient hospital stay in the past 12 months OR
• Four or more emergency department visits in the past 12 months OR
• Four or more crisis interventions in the past 12 months

Due to the targeted population that the program serves, Pathways does not offer open referrals. Specific organizations may refer individuals into the program. These referral pathways currently include Sacramento Covered, Sacramento Police Department Impact Team, WellSpace Health, Elica Health Centers, Sacramento Native American Health Center, Sacramento Steps Forward, Mercy General Hospital, and Molina Healthcare. As the program expands capacity, it will accept referrals from additional local hospitals, community clinics, health plans, and housing and homeless service providers working throughout the County.

Yes. The program will add 15 additional navigators and community health workers to respond to referrals throughout Sacramento. However, Pathways is different than traditional homeless navigator programs. Rather than deploying teams of navigators to canvas different areas and briefly interact with individuals who may or may not be eligible for the program, Pathways is designed to streamline referrals and connect navigators with eligible individuals in hospitals, clinics, and in the community in real-time. Outreach workers will provide ongoing support to enrollees through a team-based approach, working with a case manager, clinicians, and a housing specialist to support enrollees on their path to health and housing stability. Altogether, Pathways will add 30 additional staff. These staff will comprise five Pathways Care Teams that work both in the field and in health care settings to serve this vulnerable population.

Pathways will serve a minimum of 3,250 individuals experiencing, or at-risk of experiencing, homelessness from November 2017 through December 2020. At full capacity, the program will have 1,000 individuals enrolled and receiving services on any given day.

Pathways uses evidence-based outreach and care coordination practices to ensure good outcomes for individuals experiencing, or at-risk of experiencing, homelessness. Individuals are referred by specific organizations, engaged in real-time by outreach workers, and enrolled in the program if eligible. Services are referred following an assessment that determines each individual’s unique needs. An inter-disciplinary team comprised of an outreach worker, care coordinator, housing specialist, and a clinician works closely with the enrollee, providing ongoing connection to stabilizing services and social supports.

Pathways pays for outreach and navigation, service coordination, case management, new housing support services, respite care, and the alignment of existing programs and data systems into a coordinated system of care. Enrollees will continue to receive on-going health care services paid for through Medi-Cal, while these other services are provided through Pathways. While the program can fund services to help individuals find and maintain housing, Medicaid prohibits paying directly for housing.

Pathways is different than other case management or navigation programs in that it provides dedicated funding, data sharing technology, and a structured process for collaboration to better coordinate existing programs, while also expanding services. To avoid duplication of services and providers working at crosspurposes, Pathways to Health + Home tracks enrollees through a Shared Care Plan that is updated in real-time through a case management technology platform. Pathways to Health + Home is also required to routinely track and report outcomes, including connection to housing services and reductions in hospitalizations.

Pathways is one component of a comprehensive strategy initiated by the City of Sacramento to address homelessness. As a Medicaid program, Pathways will provide intensive, ongoing wraparound services to help enrollees access and maintain the housing options that are available, including shared housing, board and care, and publicly subsidized units. These supports help individuals stabilize and access housing options that are available as more housing capacity is developed.

Pathways works to address the root causes of homelessness, including housing insecurity, behavioral health issues, addiction, unaddressed health conditions, and lack of community connection. The program targets and stabilizes individuals experiencing homelessness with complex needs and high utilization of health care and public safety services, freeing up scarce public resources needed to support the local economy. By connecting individuals to health and housing services, Pathways will help alleviate the negative impacts of homelessness for all Sacramento residents.

Alignment of all homeless service programs, including emergency shelter beds, with Pathways wraparound services is a key goal of the City of Sacramento. Emergency shelter provides stability and opportunities for frequent contact with service providers that can be leveraged by Pathways, making it easier for the program to actively address individuals’ needs and connect them to housing.

From May through July 2018 Pathways anticipates enrolling approximately 700 eligible individuals into Pathways. Following this enrollment surge, approximately 40 open slots will become available each month as the first group of enrollees become stable and “graduate” from Pathways through the end of the year. While each enrollee’s time in the program will vary due to differing levels of complexity and acuity, initial data show that Pathways enrollees will graduate in 6-12 months. However, it should be noted that Pathways was designed to help individuals for as long as it takes to get them to stability and there is no time limit for program enrollment. Individuals can stay enrolled and receive Pathways services until they are able self-manage and thrive independently. Pathways will closely track enrollments and graduations to gauge how many individuals are expected to be enrolled monthly from 2019 - 2020.

Enrollments in the program on are on a first come, first serve basis and are based on verification of Pathways eligibility criteria. Pathways anticipates 50 percent of total annual enrollments from referrals from the Sacramento Police Department Impact Team, which targets homeless encampments and “hot spots” with a high level of need. The remaining Pathways enrollments will be allocated based on referrals from hospitals, other navigator programs, health plans, clinics, shelters and homeless service providers.

Pathways recognizes that a large number of homeless individuals in Sacramento are currently disconnected from health care systems despite having significant and complex health care needs. Oftentimes these individuals do not seek care until it is an emergency. Pathways will work closely with the Sacramento Police Department Impact Team to enroll eligible individuals on the streets and encampments to make sure that this population receive the services needed to prevent health crises, including primary care and behavioral health interventions. Pathways will also accept referrals from other homeless navigator programs serving the City based on eligibility criteria.

Pathways outreach workers are required to make contact with enrollees at least once every other week throughout their enrollment with the program and one of those interactions must be in-person. A Shared Care Plan that identifies the enrollee’s unique needs and a treatment must be created for each enrollee within the first month of being in the program. The Shared Care Plan must be updated regularly by program staff, with each service documented every month. For enrollees receiving housing services, a housing specialist will assess the enrollee within 30 days and continue to meet weekly during the first six months of program enrollment.

The program is required to report data and achieve milestones on numerous measures for the target population. Some of the measures being tracked and reported include emergency department visits, follow-up after mental health hospitalizations, and connection to permanent housing. Furthermore, Pathways is also tracking the geographic areas associated with program referrals and outreach and has the capacity to report out the services and outcomes for enrollees by community to help demonstrate the impact and level of services provided for homeless individuals from different areas of the City.