Community Medical Centers provides medical, behavioral health, and substance use treatment to homeless patients free or at a reduced cost through its Care Link Healthcare for the Homeless Program. Care Link is based at CMC Gleason House (on the Gospel Center Rescue Mission campus at 423 S. San Joaquin St in Stockton), but all CMC locations provide homeless care. In addition, Care Link does regular outreach to homeless encampments throughout San Joaquin county. In partnership with Project Room Key, St. Mary’s, and Stockton Shelter for the Homeless, CMC provides COVID-19 screening and a range of care and case management.

The CMC Recovery Center operates as a day sobering center assisting law enforcement to divert individuals under the influence of drugs and alcohol, saving jail beds and county resources. Coming soon, the CMC Respite Center will provide transitional housing, medically-monitored withdrawal care, and substance use treatment along with medical and behavioral health care. The respite center will not require sobriety at intake.

First 5 San Joaquin’s Housing Support Program, locally known as HousingWORKs, assists families receiving CalWORKs that are experiencing homelessness, including parents of children age 0 to 5 and pregnant mothers, so they may quickly obtain permanent housing. HousingWORKs partners with Central Valley Low Income Housing Corporation to provide housing and case management services.

The services offered may include:

• • Providing move-in and rental assistance.
  • Linking families to First 5 San Joaquin home visitation services.
  • Assisting with developing housing goals.
  • Determining affordability.
  • Creating a housing plan.
  • Assisting with finding and applying for housing.
  • Obtaining documentation.
  • Understanding lease agreements.

HousingWORKs services are based on individual family needs and the availability of and eligibility for other community resources. This program works very closely with the CalWORKs Welfare to Work program to reengage families that are not currently participating.

The HousingWORKs Landlord Incentive Program offers participation incentives for landlords that want to take action against homelessness. The program consists of bonuses and incentives for all participating and eligible landlords renting a house or an apartment to a participating HousingWORKs family. Available bonuses and incentives may include a New Landlord Signing Bonus, a Take Two!! bonus for accepting an additional HousingWORKs family, a Times Two!! deposit bonus, vacancy relief funds when applicable, and a Landlord Liaison.

The California Department of Social Services funds this program. 

To learn more about the HousingWORKs program:
PHONE Andrea Handelman, First 5 Contracts Analyst at (209)953-5437
E-MAIL HousingWORKs@sjgov.org.
VISIT  www.sjckids.org.

BHS PATH Team performs outreach, screenings, and linkage to services to San Joaquin County’s homeless population who are mentally ill and may also have a co-occurring substance use disorder (SUD).
Eligible program participants must have an SMI and a co-occurring SUD, may not be a recipient of BHS mental health services, and be homeless or at imminent risk of homelessness.

The PATH team connects clients to services that often include the BHS Transition Navigation Team. From there, clients are linked to a continuum of appropriate housing and support services. This team utilizes community resources that provide independent living skills and job training to individuals with a serious mental illness (SMI). Services include referral to appropriate housing, community mental health and primary health care, job training, education supports, and case management to ensure warm-hand-offs with expedited referrals to SUD services.

The PATH team is part of a comprehensive, countywide homeless outreach program that includes the Whole Person Care pilot, the expanded BHS Mobile Crisis Support Teams, and the Law Enforcement Assisted Diversion (LEAD) program. PATH also provides screenings, consultation, and case management at two homeless shelters. It is a partner in the SJC Continuum of Care (CoC) for the homeless population and a partner in the newly developed Encampment Response Team (ERT), which serves homeless encampments on county land.

PATH is funded through a $241,025 grant from the State of California Department of Health Care Services. Two BHS employees staff the program, and as of December 2019, a total of 778 individuals were served, and 142 individuals of those were enrolled in on-going BHS services. 

The program has been in operation for more than 20 years.

Tracy Interfaith Ministries has been in operation since 1988. We are funded by donations and grants, including city and county block grants and grants from foundations and private companies. We are run by a 100% volunteer staff, so a significant portion of our budget is able to be dedicated to purchasing food and providing services. We serve approximately 2,500 clients every month. They all qualify as low-income, but they are not all homeless. We provide food, clothing, blankets, hygiene items, hand warmers, socks, hats, and masks to our homeless clients. We also work to prevent homelessness through our Families at Risk program, which pays emergency rent and utility bills for our clients.

The San Joaquin County Whole Person Care (WPC) program is designed to improve the health of high-risk, high-utilizing homeless individuals through collaborative leadership and systematic coordination among public and private entities. The program is focused on the coordinated delivery of physical health, behavioral health, housing support, food stability, and other critical supportive services. Our goal is to improve individuals’ health and well-being in a person-centered manner through more efficient and effective use of resources. 

San Joaquin County’s Whole Person Care program targets the needs of three potentially overlapping populations:

1. Medi-Cal beneficiaries assigned to the County clinic system who are high-utilizers (approximately five or more visits) of emergency services.
2. Adult Medi-Cal beneficiaries with a mental health and/or substance use disorder.
3. Adult Medi-Cal beneficiaries who are at risk of homelessness upon discharge from WPC-participating medical facilities or the county jail.

The pilot utilizes a multi-disciplinary “Whole Person Care Integration Team,” which creates an individualized care plan for each enrollee, based on assessing the enrolee’s physical health, behavioral health, and social support needs. This care plan is shared across agencies, and each client is assigned a single dedicated care coordinator. The team engages in services that include, but are not limited to: ensuring enrollees are linked to medical services and social supports, housing, appropriate placement, behavioral health, re-entry from jail, medication adherence, crisis management, recuperative care, and a long list of other engagements that assist with the clients’ health and well-being.

The Dept. Of Veterans Affairs Palo Alto Health Care System implemented a one of its kind Shelter model in Dec 2018. This model was developed to address the growing geriatric homeless Veteran population. Recent studies found that an estimated half of all homeless individuals were over the age of 50. Recent VA research has found that the current median age for homeless Veterans is 52. Similar studies have found that less than half the homeless population over the age of 50 did not become homeless after 50. This same population often displays medical conditions in line with someone 10-15 years older and often needing help with necessary life skills. To address this ever-growing population, the VA Palo Alto Health Care System implemented a new model aimed at highly medically acute homeless Veterans.

In the model’s first year, we saw a reduction in cost and use of services compared to 6-months before 6-months post-discharge from the program. The average Veterans entering this program were costing the VA over $127,000 within a 6-month time frame on Emergency Room Visits and overnight inpatient stays. The average length of stay in the program was 78-days, and 6-months post-discharge Emergency Room Visits were reduced by over half, overnights stay per emergency room visits went down by 2, from 15 to 13, and overall cost dropped down to $56,000. Due to the success of this program, replication is already being implemented in other VA systems.