Healthy and Safe Communities

Provide quality and equitable housing, health, and human services for all.

Goal 5, Objective 2

Better integrate services and handoffs within the Safety Net departments.
On Track

Updated: January 2024

Summary of Objective Implementation Status

DHS is monitoring internal client referrals, as well as those made with to and from other Safety Net departments. This data will help establish and measure metrics for better integration of services and handoffs within the Safety Net departments, such as the number of successful referrals made avoiding crisis events, the estimate of cost savings from accurate referral, and the quality of collaboration between the Safety Net departments.

Sonoma County has utilized the ACCESS Sonoma’s Interdepartmental Multi-Disciplinary Team (IMDT) technology, infrastructure, and its specialized cohorts of staff to effectively respond to those experiencing homelessness, conducting outreach, engagement and case management. 

DHS is also proactive when looking for resources to further improved integration of services between Safety Net Departments. Through the Future of Public Health Initiative, DHS has recruited a Shared Risk and Protective Factors analyst to identify areas of overlap and shared responsibility between the department’s divisions. With the First draft of the Sonoma County Department of Health Services’ Community Health Assessment and Community Health Improvement Plan, DHS has recruited Community Health Workers (CHW’s) to help members of the community to connect with DHS services. From the three-year 2021 Sonoma County Local Indigent Care Needs Program (CMSP) grant, staff is able to serve unhoused adults with complex health or behavioral health issues, exiting the county jail, hospitals, or other healthcare settings.

Coordination and Partnership Update

The ACCESS Sonoma initiative and IMDT regularly hold CoC meetings, as well as regional planning and service coordination groups within the various geographic areas of the County (West, North South, Central and East), so as to improve partnerships with community providers, jurisdictions funding similar services and also healthcare and similar partners so as to improve the IMDT model.  This includes weekly Community Transitions to Care meeting with all community Hospitals and Clinics, Project Hope with City of Santa Rosa, NCS and weekly IMDT meetings bringing together the safety net departments. 

Community, Equity and Climate Update

The public will mainly be engaged via outreach and engagement activities noted of the HEART, IMDT Expansion, CERG, WPC and Diversion teams.  They will be connecting with community, providers and the public to carry out this work on a regular basis. 

While not a main focus of the projects, the IMDT cohorts do aim to minimize climate and environmental impacts of work, utilizing lease green vehicles and reducing vehicle trips.  In addition, the WCM provides a paperless database for care coordination, and IMDT outreach staff are equipped with tablets and remote internet, so as to be able to conduct live data entry in the field, further reducing trips and use of office supplies.