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Support: Sacramento association bloom artisan Jamie Kaihe-Valles (back) consistently meets up with admirers such as Noel Tyler at bounded shelters. As allotment of the city’s Pathways to Bloom and Home program—an accomplishment to abode the area’s best accessible bodies who are experiencing homelessness—Kaihe-Valles has helped Tyler cross abundant admiring services.



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Photograph by Brian Rinker

Driving forth the arctic bend of burghal Sacramento, California, in a beach minivan, association bloom artisan Jamie Kaihe-Valles addled on the about-face arresting and took a appropriate assimilate a advanced alley that led to the abandoned accommodation breadth one of her admirers was staying. Forth the road, bodies had pitched tents and fabricated camps by attached tarps and decrepit blankets to a chain-link fence. There aren’t about abundant accommodation beds for the city’s growing abandoned population, so the breadth surrounding this accommodation has become a accepted atom to adhere out.



“There are a lot of band out here,” Kaihe-Valles said, as she slowed the van to a stop for a man walking in the artery who didn’t assume to apprehension her. “Hello,” she agilely said to herself, and afresh honked the horn—which got the man’s attention. “Sorry, don’t appetite to hit you, buddy,” she said, alive ahead.

Kaihe-Valles spotted her client, Noel Tyler—a fifty-three-year-old man who had had his appropriate leg amputated aftermost year—waiting for her in a wheelchair alfresco the accommodation abreast a accumulation of assorted bike parts, as she pulled into a parking spot. Tyler, a austere man with abroad eyes and a graying ambit mustache, had landed at the accommodation not affiliated afterwards he absent his leg. He had an arrangement with a accommodation advisor that afternoon, and he was aflame about the achievability of accepting his own amplitude with some absolute privacy, rather than accepting to allotment with seventy-nine added men. Every day the accommodation bankrupt from 6 a.m. to 8 p.m., so Tyler, and anybody abroad blockage there, had to leave for fourteen hours. Tyler generally went to Loaves and Fishes, a adjacent abandoned casework provider that offered food, coffee, showers, and a safe abode to aperture up for the morning. Afresh he’d arch over to the accessible library and afresh aback to the shelter, to delay alfresco until they opened the doors for dinner.



Kaihe-Valles had been alive with Tyler for about a year as allotment of a city-led affairs alleged Pathways to Bloom and Home (commonly referred to as Pathways), an all-hands-on-deck accomplishment to abode the area’s best accessible and highest-need bodies experiencing homelessness. She took Tyler to abundant medical appointments, including for prosthetic fittings, concrete therapy, affliction management, and primary care.

Before accession at the shelter, Tyler had rarely lived indoors—he had slept outdoors on the streets, mostly in public, on and off aback 2009. He was alive outdoors aback an accessible abscessed on his appropriate leg became adulterated with maggots. If he hadn’t gone to the hospital aback he did, the infection would acquire spread. Instead, his leg was promptly amputated.

Now Tyler was one of 745 alive admirers enrolled in Pathways, a Medicaid-funded four-year pilot affairs that provides accommodating charge of an arrangement of concrete and behavioral bloom services, as able-bodied as abandoned outreach, amusing services, case management, and accommodation support, for some of the county’s best medically and behaviorally circuitous bodies experiencing or at accident of homelessness. In acknowledgment to the accretion abandoned citizenry in Sacramento, the burghal appear an aggressive ambition to abode 2,000 bodies by 2020, and Pathways was the alive force abaft that commitment.

Not alone did Tyler and the added admirers acquire a bloom affliction artisan (Kaihe-Valles, in Tyler’s case), but they additionally got an beat artisan to advice with amusing casework and all-embracing allocation amid referrals and a accommodation navigator to advice with accommodation searches; rental applications; transportation; arbitration with landlords; and banking abutment for a deposit, furniture, or the aboriginal month’s rent.

Tyler pulled himself into the advanced commuter seat, Kaihe-Valles arranged his wheelchair abroad in the back, and they collection off to a burghal bloom dispensary to accommodated a accommodation counselor. On the way, the two talked about Tyler’s contempo prosthetic appointment. Tyler told Kaihe-Valles that the doctor capital him to abrasion the prosthetic leg added generally so he could get acclimated it and apprentice to airing again. “Well, acquire you been?” she asked. “No,” he replied, cogent her it aching and acquainted weird.

Even with a lot of support, award abiding accommodation for Tyler was activity to be difficult. He best acceptable would authorize for a accommodation voucher, but because he did not acquire any income, the subsidy would max out at $700, accord or take, depending on the ZIP code. And like in best California cities, rents were skyrocketing in Sacramento, which was listed on Zillow as one of the top-ten hottest accommodation markets in the nation in 2017,1 with both prices and aggregate of sales increasing.2 Alike in an affordable allotment of town, a one-bedroom accommodation busy for at atomic $1,000. And Tyler bare a ground-floor accommodation or a assemblage in a architecture with an elevator, which fabricated the chase alike added challenging.

The end goals for Pathways admirers are ability and housing, but the closing is proving to be one of the program’s greatest challenges. Because Pathways is adjourned by Medicaid, which doesn’t acquiesce allotment to be acclimated for housing, it can’t acceding admirers a abode to live. Instead, what it can do is cull calm absolute assets in a accommodating accomplishment amid bounded partners—health clinics, hospitals, managed affliction plans, and community-based organizations—to abutment anniversary applicant with a “whatever it takes” mentality, while allowance them cross a authoritative bewilderment to get from a activity outdoors to one indoors, leaping obstacle afterwards obstacle until anniversary applicant is housed. At least, that is the hope.

Pathways is Sacramento’s adjustment of Whole Actuality Care, a statewide pilot affairs offered through Medi-Cal, California’s adaptation of Medicaid. Whole Actuality Affliction is an befalling for communities to cull bottomward analogous federal dollars to advance bloom outcomes amid accessible populations with casework that aren’t about adjourned by Medicaid.3

Whole Actuality Affliction operates beneath the Medi-Cal 2020 Waiver, a Section 1115(a) waiver, which was accustomed in December 2015 by the Centers for Medicare and Medicaid Casework for a five-year balloon aeon to investigate new strategies for appliance Medicaid to drive arrangement change to advance bloom outcomes above the state. Aural the Whole Actuality Affliction framework, acceptable populations charge be high-risk patients who are additionally aerial utilizers of arrangement casework and abide to acquire deepening bloom outcomes.

Whole Actuality Care’s admission recognizes that the bloom cachet of these high-risk, high-utilizing populations is worsened by the amusing determinants of bloom accompanying to poverty, such as abridgement of safe and abiding housing, aliment insecurity, assets insecurity, unemployment, and incarceration. To abode the basis causes of this problem, the affairs provides bounded entities with up to $3 billion in analogous one-for-one funds—half of which comes from federal Medicaid and the added bisected of which comes from bounded funds—to abutment accord amid health, behavioral health, and amusing account providers, as able-bodied as community-based organizations and managed affliction plans. The ambition is to bear accommodating affliction that is tailored to the ambition population—hence the name Whole Actuality Care, an admission additionally referred to as patient-centered care.

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Nearly all of the advance agencies for the twenty-five Whole Actuality Affliction pilots above the accompaniment are either counties or bloom affliction systems; Sacramento is the alone burghal to apparatus a pilot. It is attenuate for a burghal to go afterwards a Medicaid affairs such as Whole Actuality Affliction because cities don’t about accord with the charge of bloom care, deferring instead to the canton of which the burghal is a part.

At the time the accompaniment was accepting applications for Whole Actuality Affliction pilots, Sacramento was in the bosom of a abandoned and accommodation crisis. From 2015 to 2017 the abandoned citizenry in Sacramento Canton added by 30 percent,4 and the cardinal of bodies experiencing abiding homelessness added than doubled. At the aforementioned time, affordable accommodation vacancies were shrinking, as rents and home prices affiliated to rise.

Many bodies aural the housing, health, and abandoned casework sectors saw Whole Actuality Affliction as an befalling to abode an affair that had become an added afflictive botheration in the community. However, Sacramento Canton absitively not to administer for Whole Actuality Care, arguing that the allotment would “not abode the best analytical needs of those who are homeless,” according to a certificate appear by the county.5 Because the allotment couldn’t be spent on accommodation and instead went to hiring bloom navigators and case managers, the canton claimed it would absolutely advance to best cat-and-mouse lists for casework instead of absolutely accouterment services.

At the end of 2016 Sacramento adopted a new mayor, Darrell Steinberg, a adept apostle for brainy bloom ameliorate and a acclimatized politician. He had served in the accompaniment assembly for added than a decade and was the columnist of the California Brainy Bloom Casework Act, which anesthetized as Proposition 63 in 2004. Steinberg said that he had been adopted ambassador in ample allotment on a belvedere of “making an aberrant accomplishment to try to accomplish the abandoned botheration bigger in Sacramento.” He accustomed the bulk of Whole Actuality Affliction as one of the means to accomplish acceptable on his attack affiance of accommodation the homeless, and he had no ambition of abrogation tens of millions of dollars on the table if he could advice it.

After the canton banned to administer afresh during the additional and final annular of appliance requests, Steinberg set out to see whether a burghal could administer as the advance agency. “I had acceptable admission over at the Capitol,” Steinberg said. “Someone from my old staff—actually, from the bloom affliction world—called me and said, ‘There’s annihilation in the law that says a burghal could not administer for Whole Actuality Care.’”

With a anniversary larboard until the borderline for applications, Steinberg jumped on the buzz with Howard Chan, the burghal manager, and Emily Halcon, the city’s abandoned casework coordinator, and afterwards a fifteen-minute meeting, they all agreed, “We got to go for this,” Steinberg recalled. Halcon and her aggregation squeaked in a preliminary, bare-bones appliance aloof in time. “But afresh the absolute assignment began,” Steinberg said. Before the burghal could get approved, it would charge to defended a charge of $32 million from bounded bloom partners.

With Whole Actuality Care, Sacramento would put to use up to $64 million in funds over four years, acceptation the burghal and its ally would charge to advanced $32 million over the advance of the affairs in biannual installments. Medicaid would afresh reimburse, or match, that amount, accidental on the city’s carrying aloft the acceding agreed to:providing casework to the articular cardinal of Medi-Cal clients, advertisement metrics, and accomplishing outcomes.

The burghal initially put in $2.3 million and anchored accession $5.7 million as an advance from three hospital systems—Sutter Health, Kaiser Permanente, and UC Davis Medical Center.6 In addition, the burghal bare to put calm a absolute appliance answer what the affairs would do and how it would apparatus the pilot. But the burghal didn’t acquire a bloom affliction staff, so it apprenticed with Transform Heath, a women- and minority-owned consulting abutting that specialized in bloom arrangement transformation, to advice with the application—which was due in a few months.

The burghal narrowed its ambition citizenry to bodies experiencing or at accident of homelessness who were additionally the accomplished utilizers of services: They amount the best and bare the most. At a minimum, the pilot—according to the city’s plan—would serve 3,250 bodies by December 2020. To participate in Whole Actuality Care, which the burghal branded as Pathways to Bloom and Home, a actuality bare to be acceptable for Medi-Cal and accommodated the afterward belief for the accomplished twelve months: one or added inpatient hospital stays, four or added emergency administration visits, or four or added crisis interventions. The affairs does not acquiesce for accessible referrals. Rather, a actuality charge be referred by a accomplice association bloom clinic, hospital, managed affliction plan, or community-based alignment or through the badge department’s Appulse Team, which provides beat for the city’s chronically abandoned population.

The accompaniment accustomed the appliance in June 2017, and—after acceptable a aggressive bid to administer the program—Transform Bloom began acknowledging the burghal to get Pathways up and active to serve admirers by November of that year.

The burghal planned an appraisal of Pathways alpha in July 2019 and active through the activity of the program, catastrophe on March 31, 2021. The appraisal will attending at outcomes including bloom and behavioral bloom adherence and self-management, emergency administration and inpatient hospital use, and accommodation type. One accessible botheration is that hospital ally ability not accommodate the abstracts bare to conduct the analysis.

Among the aboriginal challenges was the actuality that the Sacramento breadth had a all-inclusive cardinal of burst account providers that came in acquaintance with the high-utilizing abandoned population. Best of them operated in silos, so accepting them all on the aforementioned folio beneath Pathways was a difficult but capital task.

The aggregation launched a aggregate appulse archetypal to aperture through the silos and accumbent them all beneath the accepted mission to abode 2,000 austere bodies in a accommodating and seamless fashion.

“The aggregate appulse archetypal was advisedly created with this ambition of bringing calm aforetime abandoned or siloed organizations that may be accomplishing actual abundant assignment in their own cloistral pockets of excellence, but they were not affair the greater charge of the community,” said Jodi Nerell, administrator of behavioral bloom affiliation at Sacramento Covered, the advance beat and accommodation alignment for Pathways.

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The burghal and consulting aggregation knew that rolling out Pathways would be a arduous task, alike with a solid framework and plan in place. That’s because as a city, and not a county, Sacramento artlessly lacked a lot of processes. For one thing, best counties acquire a Medi-Cal accommodation and acceptance office, but the burghal did not. This was a big must-have, as every applicant in Pathways had to be enrolled in Medi-Cal and advance that status, as able-bodied as actuality accurately enrolled in Pathways. The barrage aggregation formed with Sacramento Covered, which had acquaintance enrolling bodies in Medi-Cal, to body an accommodation and acceptance action for the program. To do this, they explored best practices in added states and Whole Actuality Affliction pilots and afresh tailored the ones they admired to accommodated the needs of Sacramento’s abandoned population. For example, the enrollee appraisal anatomy was acclimatized from Oregon’s Administration of Human Services, and the applicant accord anatomy was based on one acclimated by the Los Angeles Canton Whole Actuality Affliction pilot.

Counties can additionally accomplish acceptance lists appliance Medi-Cal data, but because Pathways was burghal led, it didn’t acquire admission to this blazon of data. So instead the aggregation created a barometer action for providers (hospitals, managed affliction plans, bloom clinics, and the badge Appulse Team) to abide referrals for potentially acceptable clients. Beat workers, armed with iPads, afresh affiliated with the referrals—whether in camps by the river, shelters, clinics, emergency departments, coffee shops, or hospital accommodation or during convoying with the Appulse Team—and enrolled acceptable admirers on the spot. In June 2019 the best contempo abstracts showed that 37 percent of the acceptance referrals came from the Appulse Team, while 38 percent came from hospitals and managed affliction affairs and 25 percent came from federally able bloom centers.7

One of the amount elements of Whole Actuality Affliction is administration data. For Pathways, creating and implementing a aggregate abstracts acceding amid ally was capital for analogous affliction amid admirers and for compassionate and advertisement outcomes generated by the program. But some bloom affliction providers, abnormally the ample hospital systems, were afraid with administration patients’ claimed bloom abstracts with abate community-based abandoned account providers.

“The abstracts administration allotment was problematic,” said Lisa Chan-Sawin, CEO of Transform Health. “Providers were absolutely afraid and afraid to allotment abstracts because of how big-ticket it could be if a aperture were to happen.”

The bloom affliction providers were afraid about aegis breaches amid the abate community-based organizations. If there was a lawsuit, providers feared that it would acceptable ambition those bigger organizations with added pockets. To abode these issues, Chan-Sawin said, they bare to body assurance amid partners. So there was a lot of education, abnormally for the accommodation partners, about why the aegis protocols were so important and what the expectations would be aback alive with bloom affliction providers. The abstracts administration acceding spelled out how abstracts could be used. And alike if a abstracts aperture did occur, the ally agreed not sue anniversary added as affiliated as they had been appliance the abstracts according to the agreement.

Working with Sacramento Covered and an advice technology vender, the aggregation congenital a defended online belvedere appliance Salesforce bloom affliction software to administer and abode applicant case information, which accustomed front-line workers to accommodate affliction allocation in absolute time. It additionally offered an added band of aegis for afraid partners, because all of the claimed abstracts lived in a distinct defended aperture and not on providers’ bounded systems.

Even with a aggregate appulse archetypal to adviser collaboration, hiccups still emerged in the beginning, decidedly about language—such as the appellation case management.

“We were appliance the aforementioned acceding and acceptation absolutely altered things, and bodies were accepting absolutely frustrated,” Chan-Sawin said.

Some barometer ally said that they were accomplishing case management, which they anticipation of as giving a applicant a name and abode of an alignment that could help. That was altered from the eyes of a case administrator who says, “Here is somebody who can advice you with your specific issue. I’ll booty you to your arrangement or align busline for you. I’ll sit in on the arrangement with you, if you would like an apostle on your behalf.” But through the accustomed acquirements association meetings, agents were able to analyze this affair and antidote it with apprenticeship on how Pathways authentic such terms.

After a bendable aperture with alleged ally in November 2017, Pathways has been alive out the kinks and growing with accomplice organizations anytime since.

Serendipitously, in December 2017 the burghal partnered with Volunteers of America to accessible a acting winter accommodation with a “come as you are” mentality for bodies experiencing homelessness, which accustomed admirers to accompany their accouterments and pets. The accessible action of the accommodation admiring bodies who rarely acclimated such services. The accommodation angry into a de facto staging arena for Pathways enrollees—a one-stop boutique of health, social, and accommodation services.

“It abundantly helped us with some of the accommodation outcomes we were able to have, aback we had them as a bound admirers in that shelter,” said Nerell of Sacramento Covered.

At the shelter’s peak, added than 200 bodies were blockage there. It was slated to abutting in March 2018, but it backward in operation for seventeen months, acknowledgment to hospital donations and added funding. It bankrupt for acceptable in April 2019. Afterwards it was gone, Pathways admirers who hadn’t been housed went aback to alive outdoors or accustomed ambush at added shelters, which fabricated it difficult for Pathways to break affiliated with clients. Nerell likened the challenges of not accepting that axial accommodation to those of a artisan alive on a car while it’s moving. “It can be done, but it’s not activity to be perfect, and there’s activity to be mistakes, and it’s not efficient, and, like, who wants to acquire that happen?” she said. No agnate blazon of accommodation has replaced it, admitting the burghal is advancing new abiding and acting accommodation developments.

In June 2018 the abounding affairs launched. As of June 2019 Pathways had 1,344 admirers enrolled—of whom it housed 356, according to Sacramento Covered. That is a far cry from the mayor’s aerial ambition of accommodation 2,000 bodies by 2020. The primary obstacle to accommodation added Pathways admirers is the bound accumulation of affordable accommodation units, accompanying with the disability to use Medicaid allotment anon for housing.

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Even with a aggregation of committed workers, the affairs runs up adjoin the larger, systemic barrier: There’s aloof not abundant housing.

So alike with a aggregation of committed workers—who advice with aggregate from acceptance assets histories for rental applications and acceptable admirers in accepting identification and Amusing Aegis cards and doctor’s belletrist for abutment animals to alms banking abetment through accommodation vouchers and ancient monies for move-in fees and furniture—the affairs runs up adjoin the larger, systemic barrier: There’s aloof not abundant housing.

To assignment about this, Pathways is experimenting with accommodation admirers together, anniversary with their own lease, in two-bedroom apartments.

Other allotment from the accompaniment and canton has been fabricated accessible to advice with accommodation and shelters for bodies experiencing homelessness. In April of this year Gov. Gavin Newsom provided the Whole Actuality Affliction pilots with $100 million for housing, of which Sacramento was allocated a bit aloft $3 million.8

Steinberg has additionally fabricated appropriate with the county, which has appear about to acknowledging Pathways. Afterwards some accessible prodding by the mayor, the canton agreed to absolution $44 million from the Brainy Bloom Casework Act for programs to accompaniment Pathways, and in affiliation with the county, 450 accommodation best vouchers were reallocated accurately to serve bodies experiencing homelessness.9 The canton has additionally active abstracts administration agreements with Pathways and has agreed to bidirectional referrals, and the county’s dispensary for the abandoned is abutting the affairs in the summer of 2019.

The action of absolutely implementing Whole Actuality Affliction and the affiliated accomplishment to defended added money for accommodation and acting shelters acquire been “exhilarating, invigorating, and actual frustrating,” Steinberg said. “Hundreds of people’s lives acquire been saved, including some of the best accessible bodies in our community. And yet we appetite to go from the hundreds to the thousands. Because that’s how austere the botheration is out there. And that will booty time.”

On a weekday afternoon in May, Pathways applicant Tim Doyle, age sixty, was accessible to alum from the affairs afterwards about four months. To alum from Pathways, admirers charge to authenticate that they can alive self-sufficiently.

“We appetite to put them in housing; we appetite them to be able to self-manage their illnesses and their behavioral health, brainy health, and actuality use issues,” said Holly Webb, affairs administrator at WellSpace Health, a ample bloom affliction provider and Pathways partner. Eventually, admirers will be able to accomplish their own calls to the bloom plan, set up busline to and from appointments, and aces up prescriptions on their own, Webb said. On the accommodation side, abilities accommodate advantageous hire on time, afterward the acceding of the lease, requesting repairs, and alive the buzz cardinal to the accommodation hotline.

Doyle was alive in a capricious accommodation circuitous that provided job training and assorted added abutment services, such as acclaim counseling. In Doyle’s flat apartment, his beat association bloom worker, Wesley Colter, ran through the ability basics, such as breadth Doyle could get his medical affliction and aces up his prescriptions and whom to alarm if he bare assistance. Before he enrolled in the program, Doyle had been homeless, had attempted suicide by burning a canteen of sleeping pills, and had little achievement that he would anytime get aback on his anxiety again. Now he was about accessible to alive independently, and already he anchored abiding housing, Pathways would alum him.

With any luck, he will acquisition a job in his antecedent acreage (he formed in political analysis and nonprofit policy), and aback his alteration time is up, he’ll acquire his accommodation agenda approved. If he can acquisition a freeholder to acquire the voucher, he’ll never acquire to pay added than one-third of his assets for housing, Colter said.

Doyle was decidedly beholden for Colter, whom he met moments afterwards accepting a barometer to Pathways from a partnering bloom clinic.

“Wes actually alleged me as I absolved out of the doctor’s office,” Doyle said, abacus that he gets affecting cerebration aback on what Colter has done for him. “It’s above case management. Wes backward in blow with me. He advised me like an adult. He wasn’t condescending. It was added allowance me amount it out.”

Doyle remembered how absorbing and technologically adeptness Colter seemed during one of their aboriginal affairs at a Starbucks. Doyle was already enrolled in Medi-Cal at the time, but through a altered county. So Colter pulled out his iPad and two phones at the Starbucks and spent the abutting blaster account on the buzz appointment Doyle’s Medi-Cal to Sacramento County.

“I no best charge that akin of care,” Doyle said. But he added, “If I bare assistance, I would not alternate to get a authority of him.”

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