California Health Care Improvement Projects (CHIPs) are designed by CHCF Health Care Leadership Program participants with the goal of addressing meaningful challenges or opportunities in health care.
CalAIM and recent Whole Person Care pilot programs are redesigning how care is offered to people with complex needs in the MediCal system. Housing First models have demonstrated the importance of housing for client well-being, stability, and health outcomes, yet most communities lack adequate temporary and permanent housing options. Efforts thus far have failed to demonstrate compelling outcomes due to a combination of the small sample size and the complexity inherent in interventions for people who are unhoused and often have severe mental illness with co-occurring substance use disorder. The Healing the Streets Program (HTS) set out to test an integrated, person-centered, street-based care model that is not based on offering housing in Santa Cruz County. As a society, we tend to “treasure what we measure;” HTS designed the program uniquely focused on articulating and addressing clients’ goals.
The HTS team of Case Managers, Peers, and a Nurse Practitioner began targeted street-based outreach with an existing physical health street medicine team in February 2022 and started enrolling clients in April. HTS staff utilize motivational interviewing and a “circle chart” depicting potential areas of need (hygiene, food assistance, housing navigation, mental health, etc.) to elicit the client’s goals and begin prioritizing them.