About the Program

Pathways to Health + Home is the City of Sacramento’s Whole Person Care program and the cornerstone of the City’s commitment to housing 2,000 homeless individuals by 2020. Our mission is to improve the health, quality of life, and housing stability for individuals experiencing or at-risk of experiencing homelessness through an integrated system of care. Our vision is a city where all individuals have a home and access to adequate care. 

By placing Sacramento’s most vulnerable and fragile homeless residents at the center of a more coordinated, responsive, and sustainable health and housing system of care, Pathways to Health + Home offers a new way forward in addressing and preventing homelessness in Sacramento. 

What is Whole Person Care?

Whole Person Care is a four-year incentive program authorized by the Centers for Medicare & Medicaid through the Medi-Cal 2020 Waiver and administered by the California Department of Health Care Services.

The City of Sacramento was awarded $64 million to implement Whole Person Care from July 1, 2017 through December 31st, 2021. The City and partnering organizations contribute funding for the program, which is matched with federal Medicaid funds through Intergovernmental Transfers.

The overarching goal of the state program is to increase the coordination of health, behavioral health, and social services in a patient-centered manner. By improving the health and wellbeing of vulnerable Medi-Cal patients, including homeless individuals and high-utilizers in multiple systems, Whole Person Care promotes a more efficient and effective use of resources. The program fosters deeper collaboration and coordination between service providers by requiring pilots to form partnerships that work together to identify target populations, assess the range of health and housing needs, share data across systems, coordinate care in real-time, and evaluate health and housing outcomes.

Who We Are

Pathways to Health + Home is a partnership led by the City of Sacramento that brings together health plans, hospitals, clinics, housing and homeless service providers, first responders, law enforcement, and community-based organizations.

Partner Organizations

Why this Matters

Individuals experiencing homelessness are often the sickest and most vulnerable people in our communities.

The lack of housing and stabilizing social supports is a root cause of poor health and mental health. At the same time, untreated health, mental health, and substance abuse issues make it extremely difficult for homeless individuals to access and maintain housing. Although housing and health outcomes are interconnected, services are not unified and are often only provided in times of crisis.  

There is an urgent need to address Sacramento’s homeless crisis through a holistic and coordinated “no wrong door” approach that stabilizes and connects individuals to the right care in the most appropriate settings. Pathways to Health + Home provides a new opportunity to increase Sacramento’s capacity to serve homeless high-utilizers and create a more responsive system of care. 

Who We Serve

Pathways to Health + Home targets Sacramento’s most vulnerable individuals experiencing or at-risk of homelessness who are enrolled in or eligible for Medi-Cal. Medi-Cal is the State’s Medicaid health coverage program for low-income and vulnerable populations. 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.

Who is Eligible for the Program?

To be eligible for enrollment in Pathways to Health + Home, individuals must be eligible or enrolled in Medi-Cal and either literally homeless or at-risk of homelessness. In addition, individuals must also 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

How Can I Refer an Individual Into the Program?

Due to the targeted population that Pathways to Health + Home serves and the specific eligibility criteria for the program, Pathways to Health + Home does not offer open referrals.

Individuals who are served by specific organizations may be referred into the program by those organizations. These referral pathways currently include:

  • Aetna
  • Anthem
  • Health Net
  • Sacramento Covered
  • Sacramento Police Department Impact Team
  • Sacramento Fire Department 
  • Elica Health Center Community Clinics
  • Mercy General Hospital
  • Methodist Hospital
  • Molina Healthcare
  • Sacramento Native American Health Center
  • Sutter Health
  • UC Davis Medical Center
  • WellSpace Health

For more information, email pathways@transformhc.com

Contact Info