Mission / Focus / Goals
Our Mission / Focus /Goals are dedicated to empowering the unhoused, formerly incarcerated, and underserved individuals in our community to achieve self-sufficiency and thrive. We envision a future where everyone has access to the resources, support, and guidance they need to build a positive and fulfilling life.
When our organization becomes contracted with (CCAH) Central California Alliance for Health we will be able to accept “Medi-Cal Members” and provide (CHW) Community Health Worker services, and possibly (PSS) Peer Support Specialist services, and later this year we might be also able to expand our services, such as providing (ECM/CS) Enhanced Care Management and Community Support services if we become approved providers.
Services
(Dependent on becoming approved Medi-Cal Providers with CCAH)
Community Health Worker (CHW)
Our Community Health Services
1. Health Navigation & Resource Connection
We help community members find their way through the complex healthcare and social service systems.
Accessing Care: Assisting with appointments, finding specialists, and understanding medical paperwork.
Social Determinants of Health (SDOH): Connecting families to local food banks, housing assistance (like CHISPA), and utility support.
Government Benefits: Helping with enrollment and maintenance of Medi-Cal, CalFresh, and WIC.
2. Health Education & Coaching
Our CHWs provide culturally sensitive education to help you manage your health at home.
Chronic Disease Support: Coaching for diabetes management, heart health, and blood pressure monitoring.
Preventive Care: Information on the importance of cancer screenings (mammograms, colonoscopies) and immunizations.
Workshops: Community classes on nutrition, prenatal care, and reproductive health.
3. Individual Support & Advocacy
We act as a bridge between the community and healthcare providers to ensure every voice is heard.
Cultural Liaison: Serving as a "translator" for cultural nuances between patients and doctors, for the CHWs who are bilingual.
Medical Advocacy: Attending appointments with clients to ensure their concerns are addressed and understood.
Violence Prevention: Support for individuals experiencing domestic violence or community trauma, including connections to local safe shelters.
4. Screening & Assessment
We provide non-licensed screenings to identify needs early and prevent health issues from worsening.
Health Risk Assessments: Identifying "rising risk" indicators like high glucose or stress.
Social Needs Screening: Using tools to identify if a family is struggling with food insecurity or transportation barriers.
Referral Management: Directing clients to the appropriate licensed professionals based on screening results.
MPSS-SEVYIT
Re-entry Goals
Our re-entry efforts are led by a formerly justice involved individual, with lived experiences and that can effectively support parolees. By employing credentialed (CHWs) Community Health Worker, our organization addresses the holistic health needs of parolees, including physical and mental well-being, and a (PSS) Certified Peer Support Specialist provides invaluable empathetic guidance and navigation through the challenges of reintegration. Our formerly justice involved individual’s firsthand understanding of the criminal justice system, coupled with the CHW's ability to connect individuals with vital resources like housing, healthcare, and employment, and the Peer Support Specialist’s ability to provide emotional support, creates a powerful support system. This combination allows our nonprofit to offer comprehensive assistance, fostering successful transitions and reducing recidivism by addressing the unique barriers faced by those re-entering society. With the future addition of ECM and CS services for the justice involved, if approved by CCAH, we will be able to provide a more comprehensive set of services that will lead to better recidivism outcomes.
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Future Possible Services
(Dependent on becoming approved Medi-Cal Providers with CCAH)
Enhanced Care Management (ECM)
Our ECM services will include:
Finding a Doctor: We connect you with healthcare providers suited to your specific needs.
Appointment Scheduling: We help schedule and organize your medical appointments.
Medication Management: Assistance with organizing medications and ensuring you stay on track with refills.
Transportation Assistance: We arrange rides to and from your doctor’s office thru the Managed Care Plan
Community-Based Services: We help you apply for and connect with community services that enhance your well-being.
Follow-up Care Coordination: We ensure you have the necessary follow-up care after hospital visits.
Community Supports (CS)
Our Community Supports services will include:
Housing Navigation:
We assist individuals in finding safe, stable, and appropriate housing. Our team works with you to navigate the housing market, apply for housing opportunities, and overcome barriers to securing a home.Housing Deposits:
We provide financial support to help with housing deposits, which can be a significant barrier for individuals seeking to secure permanent housing. We aim to reduce the financial burden and help you move into your new home as quickly as possible.
Housing Sustainability:
Once housing is secured, we provide ongoing support to ensure individuals can maintain their living arrangements. This includes help with budgeting, accessing resources to cover housing costs, and offering guidance on maintaining stable housing over time.