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Pathways to Health + Home

Everyone should have a place to call home and access to comprehensive health care.

Pathways to Health and Home was a six-year collaborative program that ended on December 31, 2021. Led by the City of Sacramento, it served those experiencing/at risk of homelessness and supported them with access to customized care and housing stability.

What is Whole Person Care?

In order to address and prevent homelessness in our community, we need an innovative approach designed around our community.

Whole Person Care improves outcomes by unifying services with a “no wrong door” approach that stabilizes and connects individuals to the right care in the most appropriate setting. This increases our community’s capacity to service those experiencing homelessness and deliver a more responsive system of care for those who need it most.

The Idea

Whole Person Care means we’re placing the most vulnerable and fragile residents experiencing homelessness at the center of a coordinated, responsive, and sustainable system of care. The goal is to increase the coordination of health, behavioral health, and social services with a patient-centric focus.

By improving the health and wellbeing of a vulnerable population, Whole Person Care promotes a more efficient and effective use of resources.

The program also fosters deeper collaboration and coordination between service providers. New and existing partners work together to engage the target population, assess the range of health and housing needs, share data across systems, coordinate care in real-time, and evaluate health and housing outcomes.

The Funding

Whole Person Care was an initiative operated by the centers for care and administered by the California Department of Health Care Services.

The City of Sacramento was awarded $64 million to implement Whole Person Care from July 1, 2017, to December 31, 2020. The City and partnering organizations contributed funding for the program, which was matched with federal Medicaid funds through Intergovernmental Transfers.

Who is Eligible?

Medically eligible individuals who are experiencing homelessness or are at-risk of homelessness who also meet the following criteria:

  • Must meet hospital or city utilization criteria
  • Referrals are accepted from designated healthcare and city designated contacts

Due to the targeted population that Pathways to Health + Home serves and the specific eligibility criteria for the program, Pathways to Health + Health is not currently offering open referrals.

As the backbone of the Whole Person Care system, Sacramento Covered was responsible for building, managing, and progressing the pathways for participating individuals. Our role involved:

  • Access Dental
  • Anthem Blue Cross
  • Capitol Health Network
  • City of Sacramento
  • Dignity Health
  • Elica Health Centers
  • Halo
  • Health Net
  • Kaiser Permanente
  • Liberty Dental Plan
  • Sacramento Community Clinics
  • Molina Healthcare
  • One Community Health
  • Peach Tree Health
  • River City Medical Group
  • Sacramento Fire
  • SHRA - Changing Lives
  • Sacramento Native American Health Center
  • Sutter Health
  • The Salvation Army
  • UC Davis
  • United Healthcare
  • Volunteers of America
  • Wellspace Health

The Partnerships

Under the leadership of the City of Sacramento, Sacramento Covered helped streamline all Whole Person Care services by building and managing a system for tracking, communicating, and sharing information between participating service providers, which included:

  • Health plans
  • Hospitals
  • Clinics
  • Housing and homeless service providers
  • First responders
  • Law enforcement
  • Community-based organizations


Health outcomes and housing stability are inextricably linked. Pathways to Health + Home organized health, behavioral health, housing and social service providers into a “whole person” system of care. This delivery system model connected those who were unsheltered and living with complex medical issues, to an entire network designed to address their needs.


Pathways to Health + Home recognizes that housing is health care and as such, the partners worked together to engage the target population and secured housing that addressed their medical complexities.
All partners shared data through a centralized care management platform which allowed for real-time care coordination and evaluation of health and housing outcomes.

The Impact

Services Provided


Services Provided

Pathways Enrollees by Age

Age Range Distribution for those enrolled in the Pathways program
Ages: 18-25
Ages: 26-40
Ages: 41-55
Ages: 56-64
Ages: 65-Up

Pathways Enrollees by Age

Pathways Enrollees by Housing

Housing Type Distribution for those enrolled in the Pathways program
Transitional Housing
Permanent Housing

Pathways Enrollees by Housing Type

Housing Indicator


Services Provided

350 Enrolled into Pathways


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