Sutter Medical Center, Sacramento – Community Navigator

What is it?

The Community Navigator patrols (on foot) the .25-mile radius surrounding Sutter Medical Center, Sacramento (SMCS) and builds relationships with the local homeless and transient population, eventually connecting them with housing, community resources, transportation, substance abuse treatment and primary and mental health care. This program has been extremely successful in extending the reach of SMCS beyond the walls of the hospital and into the greater community, to ensure that appropriate linkages are drawn between the often complex medical and social needs of Sacramento’s chronically homeless population.

Who is it for?

Local homeless and transient individuals.

Why do they do it?

As a result of devastating cuts to mental health services since 2009, the number of chronically homeless individuals, often with multiple mental and physical health challenges, has climbed steadily in Sacramento County and specifically, in the Midtown and Downtown cores of Sacramento. Due to this crisis in the community, hospitals like SMCS have developed pilot programs and innovative approaches to appropriately manage this patient population, making significant investments to improve the quality of care provided to people living on the streets and needing wrap-around services, such as access to care, community resources and housing.

Impact

The Community Navigator slowly builds relationships with homeless individuals and helps provide them with such services as housing, a medical home, a primary care physician and mental health provider, alcohol and drug treatment, and other social services. Earlier this year, and in partnership with WellSpace Health (a local federally qualified health center), the hospital implemented the Street Nurse program to complement the efforts of the Community Navigator. Similar to a mobile intake outreach model, the Street Nurse is a registered nurse who works alongside the local Community Navigator. This increases opportunities to connect more homeless individuals to immediate medical care, necessary follow-up treatment and eventually a primary and behavioral health home to address the long-term health care needs for this underserved population. The Street Nurse has become a direct conduit from the Community Navigator to other Sutter Health Community Benefit programs, as well as other important programs led by partnering community-based organizations.

In the first 6 months of 2016, the Community Navigator has served 355 clients (85 unduplicated) and made 235 successful connections including (but not limited to) 48 clients housed/sheltered, 32 enrolled in health insurance and 63 mental health/primary care connections. In partnership with the Street Nurse, 129 clients have been served and were provided with primary medical care and advice. All of the patients who accept assistance are connected with social services and health services through a warm handoff from a trusted Community Navigator. In many cases, it takes weeks and even months for the Community Navigator to gain the trust of these homeless clients, but once a relationship is formed, homeless individuals work with the Navigator to access social services, obtain identification, make primary and mental health care appointments, and be linked to alcohol and drug treatment, housing, transportation and other resources needed to live a healthy life.

Contact: Holly Harper
Manager, Community Benefit, Sutter Health Valley Area
Telephone: 916-496-0971
Email: harperh1@sutterhealth.org