OUR SERVICES
Enhanced Care Management
Coordinates and refers services listed below
Services provided by Medi-Cal
Enhanced Care Management (ECM) is a comprehensive healthcare service that focuses on coordinating all aspects of a patient's health needs, including medical, social, and behavioral factors, by assigning a dedicated "Lead Care Manager" who works closely with the patient to connect them with necessary services and support within their community, addressing their unique challenges and ensuring they receive holistic care, often with a strong emphasis on addressing social determinants of health like housing and food security; essentially, it's a personalized approach to managing complex health needs by actively engaging with individuals where they live and providing support beyond just medical appointments. Key points a Community Health Worker (CHW) might highlight about ECM: Person-centered care: The focus is on understanding each individual's specific needs and tailoring care accordingly, not just treating medical conditions in isolation. Care coordination: A Lead Care Manager acts as a central point of contact, coordinating care between different healthcare providers, community services, and social support networks. Community-based approach: CHWs often play a crucial role in connecting individuals to local resources like food banks, housing assistance, transportation, and mental health services. Addressing social determinants of health: ECM recognizes that factors like housing stability, income, and access to healthy food significantly impact health outcomes, so these aspects are actively considered and addressed. Regular outreach: CHWs can conduct home visits or reach out to individuals via phone to monitor their health status, provide education, and identify potential issues before they become crises. Who might benefit from ECM: Individuals with multiple chronic health conditions People experiencing homelessness or housing instability Individuals with mental health challenges Those facing barriers to accessing healthcare due to language, transportation, or cultural factors
Housing Navigation
A Community Health Worker (CHW) performing "Housing Navigation" actively assists individuals facing housing instability or homelessness by connecting them to available community resources, navigating the housing application process, advocating for their needs, and providing ongoing support to secure and maintain safe housing, essentially acting as a guide to help individuals find and access suitable housing options within their community. Key aspects of Housing Navigation by a CHW: Needs assessment: Conducting thorough evaluations to understand an individual's housing situation, including current living conditions, income level, barriers to housing, and specific needs. Housing search assistance: Identifying potential housing options based on availability, affordability, and suitability for the individual's needs. Application support: Assisting with completing housing applications, gathering necessary documentation, and navigating complex application procedures. Benefit advocacy: Advocating for individuals to access housing assistance programs, including rental subsidies, security deposit assistance, and other relevant benefits. Landlord communication: Facilitating communication with landlords regarding housing concerns, repairs, or lease agreements. Tenant education: Providing information about tenant rights and responsibilities to help individuals maintain stable housing. Case management: Maintaining ongoing contact with individuals, monitoring their housing stability, and addressing any emerging issues. Benefits of Housing Navigation by a CHW: Community connection: Leveraging strong community ties to identify available housing options and access support networks. Cultural competency: Understanding cultural nuances and tailoring approaches to effectively engage diverse populations.
Food Insecurity
A Community Health Worker (CHW) can assist individuals with food access by identifying food insecurity needs within their community, connecting them to local food banks and pantries, helping them apply for government food assistance programs like SNAP (CalFresh in California), providing nutrition education, and advocating for better access to healthy food options, all while considering cultural and socioeconomic factors that may impact food choices and availability. Key aspects of a CHW's food assistance role: Needs assessment: Conducting interviews with community members to understand their food access challenges, including dietary needs, income level, transportation barriers, and knowledge of available food programs. Benefit application support: Helping individuals complete paperwork and navigate the application process for food assistance programs like SNAP, WIC (Women, Infants, and Children), and senior meal programs. Food pantry referrals: Identifying and connecting individuals to nearby food pantries, providing information on operating hours, eligibility requirements, and transportation options to access them. Nutrition education: Sharing knowledge about healthy eating habits, meal planning, budgeting for groceries, and cooking demonstrations tailored to cultural preferences and dietary restrictions. Community outreach: Raising awareness about food insecurity issues in the community through workshops, presentations, and collaborations with local organizations. Advocacy: Working with policymakers and community leaders to address systemic barriers to food access and advocate for policies that promote food security.
Social Services
A Community Health Worker (CHW) would describe "social services" or "SSI" (Supplemental Security Income) as a government program that provides financial assistance to individuals with limited income and significant disabilities, helping them cover basic needs like food, housing, and medical care, often accessed through a detailed application process that considers both financial situation and medical documentation of the disability; essentially, it's a safety net for people who might struggle to meet their essential needs due to health challenges that prevent them from working. Key points a CHW might emphasize about social services/SSI: Accessibility: CHWs would highlight that social services/SSI is meant to be accessible to anyone who qualifies, regardless of their background or situation. Application process: They would explain the importance of completing the application process accurately and thoroughly, which may involve providing documentation about income, medical records, and living situation. Case management: CHWs often play a crucial role in assisting individuals with navigating the application process, including gathering necessary paperwork and connecting them with relevant support services. Eligibility criteria: CHWs would emphasize that there are specific criteria for eligibility based on income level and the severity of a disability, which vary depending on the state. Benefits beyond financial assistance: They might mention that social services/SSI can also provide access to other support programs like healthcare through Medicaid, food assistance, and housing assistance.
Transportation
A Community Health Worker (CHW) can refer you to health insurance transportation services by assessing your need for transportation to medical appointments, explaining the available options based on your health insurance plan, contacting the relevant transportation provider on your behalf, and providing you with necessary contact information and instructions to schedule rides; ensuring you understand the eligibility criteria and any required documentation for accessing these services. Here's a step-by-step approach a CHW might take to refer you to transportation services: Identify the need: During a conversation with you, the CHW will ask about your access to transportation for medical appointments and if you face any barriers in getting to healthcare facilities. Explain transportation benefits: If needed, the CHW will inform you about the transportation services available through your health insurance plan, including details like eligibility requirements and how to access them. Connect with the provider: Based on your insurance plan, the CHW will contact the designated transportation provider to initiate the referral process. Gather necessary information: The CHW will collect details such as your name, contact information, appointment date and time, and the location of the medical facility to provide to the transportation provider. Provide instructions: The CHW will explain how to schedule rides, including the contact number, website, or app to use, and any specific instructions for booking appointments. Follow-up: The CHW may follow up with you to ensure you have successfully scheduled your transportation and address any concerns you might have about the process.
Health Education
A community health worker (CHW) can utilize National Health Information (NHI) materials to effectively educate community members by: tailoring the information to specific local needs, utilizing diverse communication methods like group workshops, one-on-one consultations, and culturally relevant materials, and actively engaging participants to foster understanding and behavior change while acting as a trusted source within the community. Key strategies for using NHI materials: Assess community needs: Before utilizing NHI materials, conduct thorough needs assessments to identify the most pressing health concerns within the community. This allows for targeted education based on relevant NHI information. Translate and adapt materials: Ensure NHI materials are translated into languages widely understood in the community and culturally adapted to resonate with local beliefs and practices. Utilize visual aids: Incorporate pictures, diagrams, and infographics from NHI materials to enhance understanding, especially for individuals with limited literacy.
Violence Prevention
A community health worker (CHW) can play a vital role in violence prevention by acting as a trusted community liaison, providing outreach and education, identifying individuals at risk, connecting them to necessary support services, and advocating for systemic changes to address the root causes of violence within their community. Key ways a CHW can contribute to violence prevention: Community outreach and engagement: Conduct door-to-door visits to raise awareness about violence prevention strategies and available resources. Facilitate community forums and workshops to discuss local concerns and develop solutions. Build relationships with community leaders, organizations, and local businesses to promote collaborative efforts. Utilize culturally appropriate methods to reach diverse populations within the community. Individual level interventions: Screen individuals for potential risk factors of violence, including exposure to trauma, domestic violence, or gang involvement. Provide individual counseling and support to individuals experiencing or at risk of violence. Teach conflict resolution skills, anger management techniques, and coping mechanisms. Assist with safety planning for individuals experiencing domestic violence. Refer individuals to appropriate services such as mental health counseling, legal assistance, or housing support. Youth engagement: Deliver violence prevention education programs in schools and youth centers. Facilitate youth leadership development programs to empower young people to promote positive change. Implement peer mentoring initiatives to support youth at risk of violence. Data collection and analysis: Gather information on local violence trends and patterns through community surveys and needs assessments. Identify high-risk areas and populations within the community. Share data with relevant stakeholders to inform policy decisions and resource allocation. Advocacy and policy change: Advocate for policies that address the root causes of violence, such as poverty, lack of access to quality education and healthcare, and social inequities. Collaborate with community organizations and policymakers to develop and implement violence prevention initiatives. Raise awareness about the impact of violence on community health and well-being.
Asthma Prevention
A community health worker (CHW) can play a crucial role in asthma prevention by providing culturally sensitive education, identifying environmental triggers in homes, connecting individuals to necessary healthcare services, and advocating for community-level changes to reduce asthma risks, particularly among vulnerable populations. Key ways a CHW can help with asthma prevention: Health education and awareness campaigns: Deliver accessible asthma education workshops to community members, focusing on symptoms, triggers, proper medication use, and preventative measures. Teach about the importance of regular check-ups with healthcare providers for asthma management. Share information on managing allergens like dust mites, pollen, and pet dander through home cleaning practices. Home environmental assessments: Conduct home visits to identify potential asthma triggers like mold, pests, cigarette smoke, and excessive dust. Assist residents in developing personalized home management plans to reduce exposure to triggers, including recommendations for air purifiers, dehumidifiers, and proper ventilation. Educate on the importance of regular cleaning routines and appropriate cleaning products. Trigger identification and management: Help individuals identify personal asthma triggers through detailed questioning and symptom tracking. Provide guidance on managing triggers like exercise-induced asthma, weather changes, and stress. Advocate for workplace accommodations for individuals with asthma if necessary. Medication adherence support: Ensure understanding of prescribed asthma medications, including proper inhaler technique. Remind individuals to refill their medications on time and address any concerns about medication side effects. Assist in navigating insurance complexities to access necessary medications. Community advocacy: Collaborate with local organizations to advocate for policies that promote asthma prevention, such as smoke-free housing, green spaces, and community-wide allergen reduction initiatives. Raise awareness about asthma disparities in marginalized communities and work to improve access to healthcare services. Referral to healthcare providers: Identify individuals with potential asthma symptoms and encourage them to seek medical evaluation from healthcare providers. Facilitate communication between patients and their healthcare providers to ensure proper diagnosis and treatment plans.
Justice Involved Individuals
A community health worker (CHW) can help justice-involved individuals by acting as a bridge between them and healthcare and social services, offering support, education, and advocacy to improve their health and well-being, and facilitate access to resources. Here's a more detailed explanation of how CHWs can assist justice-involved individuals: Facilitating Communication and Building Trust: CHWs can help individuals understand their health conditions, navigate complex systems, and connect with appropriate services, building trust and fostering a sense of agency. Addressing Health Needs: CHWs can identify health-related issues, collect data, and discuss clients' concerns within the community, helping to ensure that individuals receive the care they need. Providing Support and Education: CHWs can offer informal counseling, social support, and health education to help individuals manage their health conditions, improve their well-being, and make informed decisions. Advocacy and System Navigation: CHWs can advocate for the needs of justice-involved individuals, both within the community and with policymakers, and help them navigate the healthcare and social service systems. Connecting with Resources: CHWs can help individuals access essential resources, such as housing, employment, and substance abuse treatment, which are often crucial for successful reentry and long-term well-being. Promoting Self-Sufficiency: By increasing health knowledge and self-sufficiency through outreach, community education, and social support, CHWs can empower individuals to take an active role in their own health and recovery. Coordination of Care: CHWs can work to engage individuals in care, provide appropriate, patient-centered services, and coordinate with other health care providers to ensure continuity of care upon release from jail or prison.