Healthy and Safe Communities

Summary of objective implementation status

The Department of Health Services (DHS) is monitoring internal client referrals, as well as those made 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. 

Sonoma County Department of Health Services Homelessness Services Division conducts weekly IMDT (interdepartmental multidisciplinary team) meetings with various agencies to collaborate and provide support to unsheltered individuals.  Homelessness Services Division staff from various cohorts such as Homeless Encampment Assistance and Resources Team (HEART), Homeless Outreach & Proactive Engagement (HOPE) Team, Project Homekey Team, and Solving Obstacles for Unsheltered Lives (SOUL) Team actively engage with other participating agencies.  Participating agencies include Sonoma County Probation Department, Department of Health Services Behavioral Health Division, Sonoma County Public Defender’s Office, and a housing navigator from the Community Development Commission (CDC). A care navigator working in collaboration with Healdsburg Hospital, Kaiser Permanente, Memorial Hospital, Petaluma Valley Hospital, Sonoma Valley Hospital and Sutter Santa Rosa Regional Hospital. Other healthcare providers such as Santa Rosa Community Health, Providence, and Public Health Field Nursing. Community providers such as City of Santa Rosa, City of Rohnert Park, Catholic Charities, Homeless Outreach Services Team (HOST), COTS/Mary Isaak Center (Committee on the Shelterless/(MIC), West County Community Services (WCCS), St. Vincent de Paul (SVdP), HOMEFIST/Coordinated Entry, InRESPONSE, Reach for Home (RFH), and Interfaith Shelter Network (IFSN). Sonoma County Human Services Department (HSD) Adult and Aging/Adult Protective Services, Family, Youth and Children Services/Child Protective Services, Economic Assistance, and Housing and Disability Advocacy Program (HDAP).

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.

Key milestone update 

From the three-year 2021-2024 County Medical Services Program (CMSP) Local Indigent Care Needs Grant (LICN), staff were able to serve unhoused adults with complex health or behavioral health issues, exiting the county jail, hospitals, or other healthcare settings. Since 2021, the LICN navigator supported clients in getting connected to shelter to recuperate post-hospital stay and to restart post-incarceration, while connecting clients to community resources and supports. LICN grant funding also supported 10 units of interim shelter at Los Guilicos Village, providing temporary shelter for LICN participants. The LICN grant was in effect from January 2021 until June 2024. During this period the LICN navigator received 1157 referrals for 875 clients. 32 people were housed at Los Guilicos Village, 229 were reconnected to services in the community.  Even though the LICN grant ended, the hospital navigator continues to provide care to individuals in collaboration with local hospitals in Sonoma County.

Coordination and partnership update

The ACCESS Sonoma initiative and IMDT regularly hold care coordination meetings, as well as regional planning and service coordination groups within the various geographic areas of the County (West, North, South, Central and East), to improve partnerships with community providers, jurisdictions funding similar services and healthcare and similar partners so as to improve the IMDT model.  This includes weekly Community Transitions to Care meetings 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 by the HEART, IMDT Expansion, CERG, WPC and Diversion teams.  These teams regularly connect with community providers and the public to carry out this work on a regular basis. 

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

If this objective received Strategic Plan funding, please provide amount spent to date for non-position related funding.

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