Populations We Serve.
We support Medi-Cal members with complex health and social needs who benefit from coordinated, community-based care.
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Individuals and Families Experiencing Homelessness
Individuals experiencing homelessness who have at least one complex physical, behavioral, or developmental health need and require support accessing care and services.
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Individuals at Risk for Avoidable Hospital or Emergency Department Utilization
Individuals with frequent hospital or emergency room visits that could be prevented with consistent care, coordination, and support.
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Individuals At Risk for Avoidable Hospital or ED Utilization
Individuals with ongoing health conditions or unmet needs that increase their risk of repeated hospital or emergency department use.
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Individuals with Serious Mental Health and/or SUD Needs
Individuals living with significant mental health conditions or substance use challenges who benefit from coordinated care and ongoing support.
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Adults Living in the Community and At Risk for LTC Institutionalization
Adults at risk of transitioning into long-term care facilities due to medical, functional, or social needs, who can remain safely in the community with the right support.
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Adult Nursing Facility Residents Transitioning to the Community
Individuals currently residing in nursing facilities who are interested in and appropriate for transitioning back into the community with coordinated care and resources.