Improving health outcomes for people experiencing homelessness is a key priority for the state of California. Through new cross-sector partnerships, communities across the state are expanding their capacity to provide services to people who are unhoused. Newly available supports through California Advancing and Innovating Medi-Cal (CalAIM), California’s Medicaid transformation initiative, are the vehicle for these new opportunities and enhanced services.

Cross-sector partnerships form in a variety of ways. For example, in Santa Clara County, two organizations with a decades-long history of partnership — Gardner Health Services, a federally qualified health center (FQHC), and Catholic Charities of Santa Clara County, a faith-based social services organization — deepened their relationship to develop the Highway to Home pilot. This initiative aims to identify and connect people experiencing or at risk of homelessness with Enhanced Care Management (ECM) and Community Supports, new services made available under CalAIM.

The organizations developed the Highway to Home pilotthrough participation in the Partnership for Action: California Health Care & Homelessness Learning Collaborative, led by the Center for Health Care Strategies and made possible by the California Health Care Foundation. This profile highlights the expansion of an existing partnership in Santa Clara County aimed at improving critical services for people experiencing homelessness. It offers lessons for other health care and homeless service organizations working to improve health for people experiencing homelessness through cross-sector collaboration.

Partnership Overview

The Highway to Home pilot was built upon a well-established partnership of more than 30 years between Gardner Health and Catholic Charities. Prior to the pilot, these organizations collaborated in various ways in Santa Clara County. They co-hosted community events, like health fairs, and referred clients to each other’s services. Additionally, they sat on each other’s boards or committees, and long-term staff developed deep and trusting relationships.

Historically, both organizations supported people experiencing homelessness, but did not work together under Medicaid financing. By partnering to bring the strengths of both organizations together through the Highway to Home pilot, the team was able to provide care management and housing support services before the services were covered through CalAIM and ease the launch of CalAIM services. The pilot project worked to:

1. Identify unhoused individuals who would qualify to receive new ECM or Community Supports services under CalAIM (which included housing transition navigation services, and housing tenancy and sustaining services);
2. Create infrastructure, including a referral system, to guide unhoused individuals through Medi-Cal enrollment and/or eligibility issues and coordinate care for qualified patients with the ECM team and Community Supports providers; and
3. Breakdown barriers to secure housing by centering client priorities in pilot project processes.

Takeaways for Health Care and Homeless Services Providers

The Gardner Health and Catholic Charities pilot identified key insights for using cross-sector partnerships to effectively provide CalAIM services in their community. The following takeaways can inform organizations in California and across the country that are working to improve care for people who are unhoused.

Create a “One-Stop” Shop by Integrating Health, Social and Housing Services

Through cross-sector collaboration with Catholic Charities and seed funding from Partnerships for Action, Gardner Health hired its first housing navigator. Positioned at The Window, this team member served as a vital human connection, helping to integrate housing and health services. They enabled individuals to access services during a single visit, through one contact person, at one location. The housing navigator job description required knowledge of the health care system, local resources, and housing opportunities. It also required lived experience to support members in a person-centered, empathetic, and responsive manner. The role was designed so the pilot position could prepare the housing navigator to address the nuances of CalAIM-funded services. The Highway to Home pilot leveraged The Window as a place to engage people experiencing homelessness and connect them to a wider array of care and services.

Test Processes and Strategies Before Launch

Capitalizing on the long-standing partnership between Gardner Health and Catholic Charities, the Highway to Home pilot project was designed to introduce select services that would become reimbursable under ECM and Community Supports. The pilot gave these organizations an opportunity to understand how their partnership needed to adapt to successfully implement CalAIM services. Despite their long-term collaboration, the introduction of reimbursable services required both organizations to develop processes for referrals, team roles and responsibilities, communication, and outcome tracking. By embarking on this pilot prior to the availability of CalAIM’s ECM and Community Supports services, the organizations identified processes and roles that could help facilitate implementation once Medi-Cal reimbursement became available.

Coordinate on the backend to ensure seamless support to clients. The pilot facilitated collaboration across organizations by welcoming referrals for health and housing services at The Window. This integration ensured clients received a comprehensive, whole-person approach to their needs, regardless of program funding sources, by providing a “no wrong door” access approach. For example, when the pilot was only providing two Community Supports services — housing transition navigation and housing tenancy and sustaining services — but not yet housing deposits, Catholic Charities used grant funding for deposits or rental assistance through another program, Bridges to Hope.

Involve frontline staff in program monitoring and improvement.  The pilot team held routine meetings to support cross-organization communication and problem-solving. These sessions included frontline staff, program managers, and contract and finance staff, which provided diverse perspectives on addressing client needs and improving the pilot. Frontline staff, such as the housing navigator and ECM coordinator, collected data and provided monthly updates around pilot engagement activity, including number of referrals and people housed. They were also encouraged to share recommendations on overall pilot improvements, such as process and reporting changes that could improve the client experience and workflow. Frontline staff also participated in peer convenings to share information with and learn from other pilot teams.

Engage Managed Care Plans Early and Often

As a health center providing care to Medi-Cal managed care members, Gardner Health had an ongoing relationship with Anthem Blue Cross and Santa Clara Family Health Plan, the local managed care plans (MCPs) in Santa Clara County. Catholic Charities was not a Medicaid provider and therefore did not work with MCPs. Midway through the pilot, the organizations collaborated to convene in-person meetings with the MCPs to share their work, member stories, and early pilot results. The pilot helped demonstrate to the MCPs how the collaboration between two organizations amplified their individual expertise and resources, showcasing the benefits of working together. Through these meetings, the MCPs initiated a conversation with Catholic Charities to become a direct contracted provider for CalAIM services, in addition to their role as a partner to Gardner Health. Ongoing conversations between the plans and the providers about expanding sustainable support for clients have led the MCPs to consider adding an MCP-funded community health worker position. This role would assist in navigating services, particularly for clients who may not qualify for ECM/Community Supports, but may still require assistance accessing other services and supports.

Looking Forward

The pilot helped streamline housing resources under one roof at The Window. It also strengthened the relationship between Gardner Health and Catholic Charities and created new valuable connections with MCPs. The strategic placement of a housing navigator at The Window streamlined referrals to ECM, Community Supports, and other services. Importantly, staff at Gardner Health and Catholic Charities report that clients have expressed deep appreciation for the services received.

Since concluding the initial Highway to Home pilot in July 2024, Gardner Health and Catholic Charities have sought ways to sustain the success of their collaboration. They submitted a grant application through Providing Access and Transforming Health (PATH) to fund a permanent housing navigator/outreach worker at The Window. The team is also identifying how to provide an additional CalAIM Community Supports service — housing deposits — to better serve their members. This benefit provides one-time payments that can support first-month coverage of utilities, security deposits, first and last month’s rent, and services necessary for the individual’s health and safety, such as pest control and cleaning prior to occupancy. The partnership between Gardner Health and Catholic Charities leveraged their long-standing collaboration and used the Partnerships for Action pilot effort to maximize opportunities under CalAIM, provide new ECM and Community Supports services, and ensure the sustainability of their work.