California has the largest homeless population in the country, with more than 181,000 people experiencing homelessness on any given night, including many who are unsheltered. Notably, Black and Indigenous people are overrepresented among California’s homeless population compared to their counterparts in the general population. CalAIM, the state’s initiative to transform Medicaid services, provides new opportunities to help Californians experiencing homelessness access coordinated health care, housing, and social services. The success of CalAIM rests heavily on successful cross-sector partnerships, often requiring unprecedented coordination between health and homeless services.

To facilitate new connections between the health and homeless services sectors, the California Health Care Foundation and the Center for Health Care Strategies (CHCS) launched Partnerships for Action: California Health Care & Homelessness Learning Collaborative. From July 2022 to July  2024, the collaborative brought together health care and homeless services organizations in both urban and rural areas of California to foster effective working relationships aimed at improving health care and service delivery for people who are unhoused. Participating teams collaborated on an array of projects, such as integrating substance use disorder treatment and harm reduction services into transitional housing, incorporating medical services into a street outreach program, providing care management and housing navigation services for people chronically unhoused, working with local partners to seamlessly transition people from medical respite care to permanent housing, building cross-sector collaboratives to more holistically address peoples’ needs, among others (see Table 1).

This brief draws on the diverse experiences of pilot teams involved in Partnerships for Action, providing insights on building effective cross-sector partnerships between health care and homeless services organizations. It incorporates findings from a developmental evaluation conducted by Mt. Auburn Associates that examined the facilitators and barriers to successful cross-sector collaboration.

Table 1: Overview of Partnerships for Action Pilot Teams

COUNTY/PILOT TEAMS	PROJECT DESCRIPTION
San Diego County – 211 San Diego,* People Assisting the Homeless, Health Net, YMCA, San Diego State University’s Social Policy Institute, McAlister Institute, San Diego Wellness Collaborative, and Legal Aid Society	Enhanced data exchange between health care, homeless services, and other community organizations to improve health and housing outcomes for people experiencing homelessness by creating a real-time bed availability tracker and closed loop referral engine for medical respite care services.
Alameda County –Cardea Health,* Alameda County Health Care for the Homeless, Alameda Health System’s Highland Hospital Bridge Program, and Bay Area Community Services	Created a peer harm reduction program, expanded access to medications for addiction treatment (MAT), developed a contingency management program, and adopted harm reduction practices to reduce overdose risk among people who use drugs and who reside at a transitional housing facility.
Los Angeles County – Akido Labs* and Special Service for Groups/Homeless Outreach Program Integrated Care Systems (SSG/HOPICS)	Piloted a street medicine program that uses an outreach model to engage individuals and a clinical service delivery model to provide needed care, including primary care services and behavioral health services, and MAT.
Santa Clara County – Gardner Health Services* and Catholic Charities	Employed a housing navigator to identify individuals eligible for new Medicaid services, such as Enhanced Care Management and Community Supports through a centralized, walk-up service called “The Window” that provides people experiencing homelessness access to mail and phone services, snacks, and information about community resources.
Orange County – Illumination Foundation,* CalOptima, Orange County Health Care Agency, and Orange County Housing Authority	Exchanged data and developed workflows to create a robust continuum of care for people experiencing homelessness with high hospital utilization to seamlessly transition from the hospital to medical respite care, and ultimately to permanent housing using mainstream housing vouchers.
Kings and Tulare Counties – Kings Tulare Homeless Alliance,* Anthem Blue Cross, Health Net, and CalViva Health	Strengthened partnerships between the local Continuum of Care (CoC), health plans, and community partners to better serve people experiencing homelessness through Coordinated Entry System asset mapping and gap analysis, integrating CalAIM Enhanced Care Management and Community Supports, creating new positions at the CoC focused on CalAIM coordination and implementation, and improving data sharing across sectors.
San Luis Obispo and Santa Barbara Counties – Marian Regional Medical Center,* 5 Cities Homeless Coalition, CenCal Health, Community Action Partnership of San Luis Obispo County, and Good Samaritan Shelter	Employed a homeless health coordinator to provide Enhanced Care Management to people experiencing or at risk of homelessness discharged from the hospital and facilitate cross-sector partnerships to strengthen the care continuum for those receiving care management. Analyzed street medicine and street outreach services in Santa Barbara and San Luis Obispo counties to reduce duplication of services.
Tuolumne County – Resiliency Village* and Mathiesen Memorial Health Clinic	Developed and conducted a survey to better understand the needs and desired services for unhoused community members and designed a mobile clinic to provide physical and behavioral health services.

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* Indicates the organization that served as the project lead for the pilot team.

Insights on Effective Cross-Sector Partnerships

Partnerships for Action yielded a variety of lessons on how health care and homeless services organizations can work together to improve care models and services for people who are unhoused. The following insights can help partnering organizations when collaborating across sectors.

1. Don’t Just Talk, Do Something: Collaborate on a Project

There are many cross-sector collaboratives that primarily focus on information sharing, but Partnerships for Action took a different approach. It brought stakeholders together to address a thorny challenge that no one organization could solve alone. This action orientation not only led to tangible outcomes for people experiencing homelessness but also deepened understanding and trust, and, in many cases, established a foundation for ongoing partnership. 

Clearly documenting what you are trying to do and how you will move forward can be helpful grounding when bringing cross-sector stakeholders together to advance a project. Partnerships for Action teams created action plans to align around a shared vision and goals, so that they understood what each organization was working toward. Teams updated action plans quarterly allowing them to recognize progress, pivot as needed, and clearly articulate responsibility for next steps. Any collaborating team can use a simple template to structure work steps, set deadlines, and ensure clarity of roles.

Teams should not let developing the perfect plan get in the way of getting started. Partnerships for Action teams suggest that perhaps it is better to get going, learn from doing, and adapt as needed rather than risk “analysis paralysis.” This was evident in the work in San Diego County. The team initially created a “minimum viable product” to share information related to bed availability among existing recuperative care and short-term post-hospitalization housing providers to inform a shared intake and referral tool. The early scoping of the data-sharing tool provided the opportunity for the project team to gather insights from various stakeholders (e.g., managed care plans, hospitals, housing providers, skilled nursing facilities) and ultimately publish a report offering community recommendations, and eventual expansion of the San Diego Community Information Exchange (CIE) to include a real-time bed availability tracker and closed loop referral engine for medical respite care services.

In Los Angeles County, SSG/HOPICS and Akido Labs also embraced a learn-by-doing approach that ultimately led to a new street medicine model of care and a robust foundation for ongoing care delivery partnership between the organizations. The organizations committed to finding a path to deliver street medicine that leveraged the medical expertise of Akido doctors and the authentic relationships, patient knowledge, and outreach capabilities of SSG/HOPICS, one of the largest housing and homeless service agencies in Los Angeles County. Staff at both organizations learned how important it was to set aside time to reflect on what partnership elements were required to support the model of care. The team started with, in their words, “a loose, collaborative approach” and turned it into multiple funded programs with clear contracts, and clearly defined roles. By testing a variety of approaches and fine-tuning, they identified an effective platform to share essential data with one another. They also drafted a multi-agency service agreement that serves as a statement of work for the model of care that reduces the lift required in future contracting. With these pieces in place, the partners are pursuing more joint grant applications and expanding services that they provide together, including adding additional medications for addiction treatment and harm reduction services. 

2. Get to Know Your Partners

While it is crucial to focus on the work at hand, it is equally important for partnering organizations to carve out time to connect with each other. Building these connections deepens understanding of each other’s organizations and the sectors they represent. With a better understanding of individual and sector-specific values, limitations, and incentives, partnering organizations are better positioned to tackle not only the immediate project but the next challenge that arises. 

Communication can be a starting point for understanding other sectors. This includes understanding differences in terminology, especially clarifying the acronyms used by each sector, and ensuring that when organizations from different sectors use the same word, that all parties understand the meaning of terms. In Kings and Tulare counties, the health plans and the CoC had existing relationships that the pilot and other efforts, including the Department of Health Care Services Housing and Homelessness Incentive Program allowed for the creation of more robust partnership. The CalAIM coordinator, funded by the Housing and Homelessness Incentive Program for the Kings and Tulare pilot, highlighted the importance of clear communication noting that in meetings with practitioners from both health care and homeless services it was important to “go through the lingo of things and just make sure everyone was on the same page.”

The Partnerships for Action teams demonstrated a variety of ways to build relationships among the partners. First, leave room in meetings to not just discuss actions needed to advance the immediate work together but also leave time to share about each other’s capacities, limitations, and aspirations. In Partnerships for Action, the team from San Luis Obispo and Santa Barbara counties prioritized time for “problem-solving and problem dissection discussions” that allowed stakeholders to get to know one another and share insights about the broader system of care for people experiencing homelessness in both counties. Ultimately, the San Luis Obispo and Santa Barbara stakeholders found these insights among the most impactful outcomes of their participation in Partnerships for Action. This understanding helped stakeholders recognize their organizations can complement each other, not compete with, in working toward their shared goals.

In-person time together was also powerful in building deeper relationships. Stakeholders in Alameda County conducted site visits to each other’s facilities. As a result, case managers and their supervisors better understood what services and providers are available and who can help meet their clients’ needs. The team also hosted in-person trainings to support increased awareness of the project, foster team building and alignment of shared goals, and enhance staff knowledge and skills in working with people who use drugs and understanding available treatment options. Attending conferences together was also a powerful accelerant to relationship development. The teams in Partnerships for Action traveled to convenings together twice during the initiative and several stakeholders highlighted the benefit of joint exposure to new concepts and innovative practices. This shared learning can also happen outside of the initiative context. The team from San Luis Obispo and Santa Barbara counties noted a similar benefit when team members jointly attended a national conference on health care for people experiencing homelessness.

3. Create Mechanisms for Accountability

Effective structures for accountability provide the framework necessary to drive impactful work forward. Teams participating in Partnerships for Action benefited from structure and accountability to move their project work forward. For example, the team from Alameda County created three project workstreams and divided staff into three teams, each tackling one of the workstreams. The team also benefited from Alameda County Health Care for the Homeless’ experience as a convener and hub — overseeing organizations and programs and contracting with external partners to implement programs. This expertise helped the team establish its structure.

In Orange County, the team initially met bi-weekly to discuss the project but later shifted to monthly meetings, realizing they needed more time to complete their work in between meetings. To ensure accountability and progress, it is important for cross-sector partnerships to define their approach, assign responsibilities for tasks and/or workstreams, and determine a consistent meeting schedule.

Resources such as work plans, tools, and monthly technical assistance calls throughout the learning collaborative supported team progress. Other communities could consider partnering with an external consultant to hold stakeholders accountable or assign a person or an organization on the team as the community partner responsible for monitoring the project’s progress.

4. Employ “Boundary Crossers”

“Boundary crossers,” or people who have experience working in one sector and then move to work in another, play a crucial role in facilitating relationship development and progress between collaborating sectors. Sometimes boundary crossing happens organically, while other times it is driven by system-created positions explicitly aimed at enhancing collaboration and integration between sectors. During the two-year Partnerships for Action initiative, a few learning collaborative members who previously worked in the homeless services sector moved to positions in Medi-Cal managed care plans. These people brought a keen understanding of homeless services to managed care, along with the language, relationships, and skills to facilitate collaboration between these two fields. Organizations aiming to collaborate with partners in other sectors might consider hiring individuals with that experience to support cross-sector efforts.

For example, Kings and Tulare Homeless Alliance, the local Continuum of Care in Kings and Tulare Counties, worked with its local managed care plans to create the CalAIM Coordinator position. Funded by Anthem Blue Cross, Health Net, and CalViva Health, this role focuses on building relationships across health care, housing, and homeless services providers and integrating CalAIM services into the homeless response system, including current and future interim and permanent housing models. Since creating this position, the health plans have seen increased uptake of Medi-Cal members receiving Enhanced Care Management and Community Supports housing services. This model can be replicated in other communities to bridge gaps, facilitate relationships, and further integrate health care and homeless services systems.

5. Support Dynamic Partnerships

Cross-sector partnerships will, and should, evolve over time. Sometimes, partnerships evolve naturally. For example, when a person retires or transitions to a new role or organization, those transitions require teams to reflect strategically on their next move. During Partnerships for Action, for example Gardner Health Services and Catholic Charities of Santa Clara County experienced this evolution in a few ways. At the start of their project, the team hired a housing navigator whose position was central to their project. Soon after, the individual had to leave for personal reasons. This required the team to rethink their project timeline, regroup, adjust staff roles and responsibilities, and recruit a replacement. Another example is when a core team member and leader at Gardner Health Services, who had a strong relationship with Catholic Charities’ leadership, retired toward the end of the project. The team carefully planned for their colleague’s departure and ensured that other staff at the partnering organizations had relationships to help carry the work forward.

The team in San Diego County also navigated changes to their team structure. During the project, Health Net, a Medicaid managed care plan, exited the market in San Diego County due to changes in the policy environment. This resulted in the team losing a critical team member and representation from managed care. The team in San Diego shifted project timelines to account for relationship development with new plan partners and adjusted workflows to consider health plans entering and exiting the market.

At other times, partnerships evolved intentionally. During the two-year initiative, the team in Orange County reflected on the progress of their work, which focused on creating a continuum of health care services and linkages to mainstream housing vouchers for people in recuperative care. The team realized that they needed to strengthen their relationship with the Orange County Housing Authority that is responsible for setting aside mainstream housing vouchers for people participating in the team’s pilot program. To do so, the team established weekly case conferences with the Housing Authority to keep them apprised of clients who might be ready to receive housing vouchers.  

Partnership for Action teams needed dedicated time and structure to think about who to engage in their evolving partnership. For example, at the mid-point in-person convening for Partnerships for Action, Mt. Auburn Associates led teams through a ‘results in the center’ exercise, encouraging pilot teams to reflect on how they can nurture, accelerate, and sustain their collaborative work.

6. Involve the Community

Engaging people experiencing homelessness and/or those with lived experience of homelessness offers valuable insights that can inform the development of programs that will impact them and their community. Through Partnerships for Action, for example, Resiliency Village, a local homeless services provider in Tuolumne County, partnered with Mathiesen Memorial Health Clinic, a tribal federally qualified health center, to build a street medicine and mobile outreach program. In building the program, Resiliency Village and Mathiesen collaborated to create a survey aimed at better understanding the health and social needs of the county’s unhoused community, their experiences related to homelessness, and their perceptions on access to care and services. Employees with lived experience administered the survey, collecting over 75 responses. The survey results are helping Resiliency Village and Mathiesen design their care model and educate the community about the backgrounds and needs of their unhoused neighbors.

Similarly, the Alameda County team had people with lived experience of homelessness inform and lead their pilot program. The team created a suite of substance use disorder and harm reduction programs available at a local transitional housing facility. Prior to launching the programs, the team hosted five focus groups with residents at the housing facility to gather their feedback. One of the themes that emerged from the focus group was feelings of isolation and loneliness among residents. This informed the creation of a drop-in space to create opportunities for residents to connect with peers. In addition, the Alameda team hired three peer harm reduction specialists with lived experience to run the programs and support residents in accessing services. More broadly, people with lived experience of homelessness played an advisory role in Partnerships for Action. They supported the selection of pilot teams and participated in learning collaborative sessions, where they presented and informed group learning and project activities. Organizations looking to improve health and homeless services systems through cross-sector partnerships can engage people with lived experience. This engagement can take various forms, such as hiring people with lived experience, hosting focus groups, soliciting input from or developing a community advisory board, conducting surveys, and more. Programs can start by assessing community needs through detailed conversations, focus groups, or other mechanisms involving current or former service users. Involving staff and clients with lived expertise in planning and ongoing evaluation can help ensure that the program is responsive to the community’s changing needs. Organizations can also consider having positions requiring lived experience on their board of directors with equal voting rights to inform the overall direction of the organization. Whenever possible, these positions should be paid.

7. Identify Opportunities for Broader Systems Impact

When starting a cross-sector project, it is important to consider how the partnership impacts broader systems change. Ideally, if the work is successful, it can move from a group of individuals collaborating, to a group of organizations partnering, and eventually, systems working in coordination with each other. Teams participating in Partnerships for Action demonstrated ways to bring a systems perspective to their work. For example, homeless services and health care partners in Tulare and Kings counties mapped out local resources available to support people experiencing homelessness. Stakeholders across the two counties engaged in a human-centered design activity to identify gaps in services and priorities for their partnership. This process highlighted opportunities to leverage CalAIM funding for needed housing services in communities historically lacking traditional federal, state, and local housing funds. The collaboration of stakeholders from both counties and multiple sectors led to greater coordination, impact, and solid relationships, paving the way for future CalAIM opportunities.

Other teams actively disseminated insights from Partnerships for Action to the broader community. For instance, Resiliency Village and Mathiesen Memorial Health Clinic worked with HC2 Strategies to synthesize survey findings of community members experiencing homelessness. HC2 Strategies helped the team create a presentation outlining the history and needs of unhoused Tuolumne County community members, which is now used to educate community stakeholders. The team aims to create a broader impact beyond their partnership by sharing survey data with community partners, hoping to shift perspectives on homelessness and improve local resources for people who are homeless.

Team composition can also impact the spread and scale of cross-sector collaboration. Teams should consider including their organizational leadership, or at a minimum, keeping leadership apprised of their goals and progress to help transition from individual staff working together to organizations collaborating across sectors. It is important for teams to inform leadership of the value of the partnership, including potential impacts such as return on investment and reputational gain. Teams should also think about including entities that have significant impact on systems. From the homeless services sectors, this could mean including Continuums of Care, entities tasked with coordinating homeless services in a given community or region. From the health care sector, this could mean including managed care plans, large hospital systems, and county agencies that can help spread cross-sector efforts.

Looking Ahead

To meet the health and social needs of people experiencing homelessness, it is critical for the health care and homeless services sectors to effectively partner with each other toward a shared goal. In California, the promise of Medi-Cal transformation requires
close partnerships between health care and homeless services organizations. The eight teams under Partnerships for Action offer lessons on cross-sector collaboration that other communities can learn from to inform their cross-sector efforts.

Beyond these insights, communities in California can use resources that are available to support cross-sector collaboration. For example, the Providing Access and Transforming Health (PATH) Technical Assistance Marketplace offers free resources and technical support to help organizations implement Enhanced Care Management and Community Supports. Additionally, the PATH Collaborative Planning and Implementation Initiative supports local or regional planning for Enhanced Care Management and Community Supports, and more broadly for developing connected communities of care.