Blog Post
Community Clinic Case Study: Los Angeles Christian Health Centers Health Home Program

Community Clinic Case Study: Los Angeles Christian Health Centers Health Home Program

May 27, 2020

How One Los Angeles Area Clinic Addresses Housing Insecurity and Homelessness

Implementing new programs can pose operational challenges for seasoned staff and leaders at any organization. Even with a well-planned approach to program roll out, unforeseen setbacks and difficulties can create difficulties. New staff roles and responsibilities, paired with barriers preventing patient access to care, all magnify the challenges community-based organizations must navigate to provide care. By emphasizing people and partnerships, exercising flexibility, and exploring innovative thinking, Los Angeles Christian Health Centers (LACHC) demonstrate how they implemented best practices in serving their patients facing housing insecurity and homelessness.

Organizational Overview

LACHC has been providing services to the most underserved communities in Los Angeles since 1996. Founded by the Los Angeles Mission, LACHC has grown to 12 sites, serving more than 11,000 patients with a comprehensive list of medical, dental, and mental health services for uninsured individuals in both the Skid Row area of Los Angeles and Boyle Heights.

As a Federally Qualified Health Center (FQHC) that provides low- and no-cost health care, LACHC pride themselves on their collaboration with community partners including shelters, public housing projects, mental health organizations, academic institutions, and churches. LACHC’s relationships allow them to provide comprehensive care management services, which include:

  • Medical
  • Dental
  • Social support
  • Laboratory
  • Radiology
  • Specialty referrals
  • Mental health
  • HIV testing/treatment
  • Pharmacy
  • Mammogram program
  • Medical outreach service delivery
  • Substance use treatment
  • Optometry
  • Outreach/enrollment
  • Immunizations/TB testing
  • Health education













The Program

Despite efforts by Los Angeles County and neighboring health centers to address the crisis, an unprecedented number of people are experiencing housing insecurity and homelessness. According to L.A. Care Health Plan, homelessness increased by nearly 6% from 2015 to 2016. In Los Angeles County, from 2018 to 2019, the number of people experiencing homelessness increased by 12%. As a result of this alarming, continual growth, Los Angeles County and public health leaders have prioritized efforts to help reverse the trend. In 2019, L.A. Care launched the Health Homes Program (HHP), which provides funding for comprehensive care management and care coordination services that address social determinants of health for Medi-Cal beneficiaries.

LACHC’s HHP Program Overview

Organization Los Angeles Christian Health Centers
Project Health Homes Program
Purpose To identify the top 4-5% highest-risk Medi-Cal members
Eligibility (at least one from each in row)
  1. Chronic Condition
    • At least 2 of the following:
      • Chronic obstructive pulmonary disease
      • Diabetes
      • Traumatic brain injury
      • Chronic or congestive heart failure
      • Coronary artery disease
      • Chronic liver disease
      • Chronic renal (kidney) disease
      • Dementia
      • Substance use disorders
    • OR
    • Hypertension and one of the following:
      • Chronic obstructive pulmonary disease
      • Diabetes 
      • Coronary artery disease
      • Chronic or congestive heart failure
    • OR
    • One of the following:
      • Major depression disorders
      • Bipolar disorder 
      • Psychotic disorders (including schizophrenia)
    • OR
    • Asthma
  2. High Acuity:
    • Has at least three or more of the HHP eligible chronic conditions
    • OR
    • At least one inpatient stay in the last year
    • OR
    • Three or more emergency department visits in the last year
    • OR
    • Chronic homelessness
  • Comprehensive Care Management
  • Care Coordination
  • Health Promotion
  • Comprehensive Transitional Care
  • Individual and Family Support Services
  • Referral to Community and Social Supports
  • Housing Navigation and Tenancy Support (for enrollees experiencing homelessness)
Funding Source Medi-Cal, administered by L.A. Care


Five Key Lessons Learned

With the support of its leadership team, LACHC identified the following lessons learned as essential to successfully address the needs of patients who are experiencing housing insecurity or homelessness: 

  1. Patients are at the core of the work. To address the challenges of those who are housing insecure or homeless, LACHC focused on building rapport with patients through extensive outreach provided by well-trained care coordinator staff. These staff focus on building personal connections to individual patients, as well as communicating the program benefits. Clear, easy-to-read welcome packets and communication tools provide an additional resource to connect patients more easily with program benefits. The “HHP Welcome Packet” is an example of such materials LACHC created.  
  2. Create policies that motivate and engage staff. To effectively implement the HHP Program, LACHC focuses effort on engaging staff and providers. LACHC has developed comprehensive policies, processes, and decision diagrams to ensure staff and providers understand the eligibility requirements for patients. By focusing on the providers’ and staffs’ understanding of program priorities through robust training and communication, LACHC has improved the collective awareness of HHP and ensures everyone is on the same page in support of the program’s mission. The “Health Homes Program Eligibility – CCA” document exemplifies LACHC’s efforts in creating a clear process to support staff and provider understanding of the program.
  3. Get involved with the community. The LACHC team has benefited greatly from leveraging new - and existing - partnerships with community-based organizations. By getting involved in county and city policy groups, LACHC staff better understand local programs and policies that support their HHP work. For example, LACHC attends county-led Homeless Policy Deputy Meetings as a way of participating in local government, which in turn enhances their programmatic efforts. 
  4. Think outside the box. Innovative thinking spurs creative solutions for addressing everyday challenges. LACHC constantly prepares for shifts in funding, including: considering the allocation or re-allocation of resources when activities don’t produce expected results, leveraged existing and new partnerships to build upon program work, and managing the changing environment resulting from the COVID-19 pandemic. Notably, LACHC leverages Health Fellows from the AmeriCorps program, administered by the Community Clinic Association of Los Angeles County (CCALAC),  to support the increased quality of contacts with patients participating in HHP.
  5. Preparation for adapting to working with patients with complex needs. Patients experiencing housing insecurity or homelessness have complex care needs which require providers, care coordinators, and community outreach workers to have specific skill sets that enable them to meet patients’ needs and anticipate rapid shifts in their work environments. LACHC undertook an organizational restructuring to allow two general case managers to focus primarily on patients who are experiencing homelessness or housing insecurity. This shift positioned those two case managers under the Care Coordination Department, updated their title to “care coordinators”, and realigned their job responsibilities to create consistency across their and the other care coordinators’ work at LACHC. This organizational restructuring allowed care coordinators and community outreach workers to focus their efforts on the specific and complex needs of patients experiencing housing insecurity or homelessness.  

Join Us

Sign up to learn about the latest health workforce research insights and leadership opportunities from Healthforce Center, an organization dedicated to helping health care organizations drive and navigate change.


The funding for this case study was provided by L.A. Care Health Plan.