Santa Rosa Community Health Clinic in homeless services center pays dividends

Locating a community health clinic in Caritas Center leads to better health outcomes and a quicker path to housing |

Two years after opening Caritas Center, its downtown Santa Rosa family shelter and services hub, Catholic Charities believes it has successfully tested a key piece in the puzzle of solving homelessness: improve the health of people who are homeless.

The North Bay’s largest provider of homelessness services arrived at that conclusion based upon an ongoing partnership with Santa Rosa Community Health, or SRCH, a local consortium of community medical care clinics.

Under the arrangement, SRCH opened a full-service clinic — the Santa Rosa Community Health Clinic — in Caritas Center three months after it opened in August 2022.

The results of that collaboration have been better health outcomes for people who are homeless, including fewer repeat visits to hospitals and emergency rooms. Those improvements have resulted in people being placed more quickly into housing, the two organizations say.

A recently released, jointly produced new policy paper by Catholic Charities and SRCH, “United in Health and Home: a Progress and Challenges Brief,” puts it bluntly: “Health and homelessness are inextricably linked: to solve homelessness, we must examine it through the health lens.”

The paper was made public on Thursday during an event held at Caritas Center for elected officials, policymakers, donors and other supporters.

“The synergy between Caritas Center and the Santa Rosa Community Health Clinic exemplifies the power of proximity,” Catholic Charities CEO Jennielynn Holmes said to a crowd of nearly 100 people gathered in the facility’s drop-in center on Sixth Street.

According to the paper, in its first year, Catholic Charities served 2,242 people, a 13% increase from before the center opened.

In the nearly two years since it opened the Caritas Center clinic, SRCH has served 4,270 patients, including 319 under the age of 18, as well as 86 who were pregnant.

The paper also highlights that in the first year of Caritas Center operations, Catholic Charities “was able to permanently house individuals in half the time (an average of roughly three months) it took before we had Caritas due to the increased rooms for families, a larger Drop-In Center, and our new Nightingale recuperative care program.”

The 33-bed Nightingale program at Caritas Center is where people who are homeless can recuperate after hospital stays, instead of returning to the streets or shelter system. The paper recommends increasing the number of such facilities to assist people in transitioning from hospital care to housing.

Located together, working together

The fundamental mechanism at work in the collaboration between Catholic Charities and Santa Rosa Community Health is locating health care services in a place where people who are homeless are also being supported in a variety of other ways (which at Caritas Center includes shelter, interim housing, a preschool and other youth and family services).

As the policy paper puts it: “The foundation of Caritas Village is built on partnerships and providing a full continuum of care and services for those who come to our front door, creating access to resources all in one location.”

That has made it possible to more easily and efficiently deliver an array of health care to people visiting or staying at Caritas Center, who otherwise face significant barriers to accessing it, ranging from lack of transportation to a lack of trust in providers. Also, SRCH operates a fully equipped van that makes the rounds of other shelters and encampments, to offer health services and also encourage people to visit the Caritas Center clinic and drop in center.

Both the permanent and the mobile clinics are examples of the increasingly favored principle of meeting clients where they are, said Santa Rosa Community Health CEO Gaby Bernal Leroi, who co-authored the policy paper with Holmes.

“It allows our medical team to build trust because you are out there looking for them, available to them wherever they are. And then they can also come and find you at the center,” Bernal Leroi said in an interview. “The meeting-them-where-they're-at concept is really about familiarity and building trust with the individual.”

The partnership makes it easier for SRCH staff to stay on top of the health needs of patients who are homeless, Bernal Leroi said. For example, if a patient misses an appointment and shows up at Caritas Center for other reasons — such as visiting the drop in center or using other services — Catholic Charities staff can alert clinic personnel who can then reach out to the patient.

“It's so much easier to keep tabs on the clients, if you will, and make sure that they are accessing the other services, because we can walk them down to get a referral for shelter or to get a shower, and then Caritas can walk them up,” said Bernal Leroi.

“The proximity just makes it easier for both of the organizations to be able to conduct better follow-up to make sure that these patients are not lost to care, or are following up with the other set of services that they need. We're just able to hold them tighter,” she said.

Likewise, not having to send people who need care to a hospital or another clinic is critical to helping get them off the streets and permanently housed, Holmes said in an interview.

“We can stay engaged with them longer to reduce the length of time to housing. That is a big part of what we struggle with,” Holmes said. “And so having it all comprehensively on one site not only helps their health, but it helps us keep them in with us and engaged.”

Addressing other needs

Meanwhile, locating services under one roof has made it easier for staff at both agencies to work to address other needs that figure into one’s overall health and are faced by people in vulnerable conditions who may have lived on society’s margins for extended periods: legal documents; mental health counseling; substance abuse treatment; transportation; and dietary needs.

Taking care of those needs helps people prioritize their health.

“When you're worried about where you're going to sleep and what you're going to eat and your safety, it's very hard to think about the next level of things that you need in your life to be able to get better,” Bernal Leroi said. “If you're always focused on the bare necessities, it's hard to move forward in any way. And so this partnership allows us to move patients into the next level of being able to be ready for housing.”

To coordinate that network of care, each community health clinic client is assigned a case manager, an approach funded through a state initiative called CalAIM, intended to improve outcomes among low-income Medi-Cal recipients by expanding the type and number of services the state will reimburse providers for.

The policy paper credits CalAIM as one factor in improving outcomes for clients. The initiative makes enhanced case management a reimbursable benefit. The paper says it creates a “funded pathway to provide the hands-on case management (both medical and social) they need to navigate complex medical conditions, including substance use, and complete all the steps on the path to get into and stay in housing.”

However, the paper says, CalAIM — which, in a significant first, now provides rental security deposits for qualified people — could have greater impact if it covered a greater array of housing-related costs, as similar initiatives have in some other states.

Other recommendations the paper makes include expanding street medicine and mobile health services and locating more health and homeless services facilities together in the same manner as Caritas and SRCH.

“We need to make medicine as mobile as the people. And every shelter or homeless services intervention needs to have a medical component to it,” Holmes said.

You can reach Staff Writer Jeremy Hay at 707-387-2960 or jeremy.hay@pressdemocrat.com. On X (Twitter) @jeremyhay