The cohort teams are multidisciplinary teams across the departments that coordinate care for a group of ACCESS participants that meet participation criteria and requirements for the Cohort. The team is comprised of frontline staff across the Safety Net Departments. They coordinate the care plans and service goals for cohort participants.
Team members are subject matter experts including clinical case managers who conduct client outreach, assessment, and case management; eligibility workers, adult protective services workers, social workers, housing navigators to help identify and recommend the availability of appropriate sheltering and housing placements; child support services specialists who provide support to participants in need of assistance with child support payments or extensions for payments; Probation officers who support those participants who are intersecting with the probation system to help support their successful participation and completion of probation, and public health disease control investigators. Each cohort team is managed by a cohort manager that is responsible for referral intake and coordinating individual cohort processes including day-to-day supervision of cohort team members and their responsibilities.
Six cohorts have been launched since the ACCESS Initiative began at the end of 2017; they include:
- Emergency Rapid Response – This cohort focused on the residents who remained in emergency shelters weeks after the October 2017 Complex Fires and the 2019 Kincade Fire. Staff members focused on engaging immediate crisis needs initially, and built relationships allowing care management and services to address chronic needs. Individuals were connected with housing, benefits, mental health services, and substance use services. After the emergency shelters closed, many individuals were willing to engage in ongoing integrated care management and moved on to other cohorts such as the High Needs Homeless cohort.
- High Needs Homeless – The High Needs Homeless cohort focuses on intensive outreach and case management to homeless or at risk of becoming homeless individuals with chronic and persistent mental health needs, chronic medical issues, substance use disorders, high utilizers of emergency medical services, frequent crisis mental health services, and criminal justice problems. Services aim to stabilize individuals linking them to resources and housing, addressing mental health and medical needs, and reducing utilization of emergency medical, acute psychiatric, and criminal justice systems.
- Emergency Department High Utilizers – These individuals have existing physical or mental health issues who do not have regular access to medical care. They may be unsheltered, and often only seek care when experiencing immediate emergency need. The cost of going to the emergency room is much higher than managing a condition and preventing an emergency. Utilizing health care in only emergency situations leads to poorer health outcomes. Additionally, costs are passed on to the health care system. IMDT members partner with our local county hospitals to identity these at risk individuals, provide integrated care management, and connect them with clinics and primary care providers for health outcomes that are both better for the individual and lower cost to the community.
- Mental Health Diversion – Focuses on mentally ill offenders who qualify for diversion. The Health Diversion cohort is a criminal justice diversion program that interfaces with both Diversion Court and ACCESS Sonoma’s IMDT members. Individuals are screened for program requirements which include being vulnerable, high end utilizers, and have a qualifying mental health condition. Once qualified by the mental health diversion team, individuals are provided services including case management, individual and group counseling, housing services, substance use screening, medication monitoring, and assistance accessing benefits. Throughout their two year court approved program, participants return to Diversion court each month for reviews of their progress in treatment. Successful individuals may have legal charges dismissed upon completion.
- Homeless Encampment Access & Resource Team (HEART) – Focuses on sheltering Sonoma County’s homeless population. This cohort was established to engage with the homeless population on the Joe Rodota Trail, the largest encampment in the County’s history. It was expanded in March of 2020 to outreach and provide coordinated care to individuals living in encampments in the unincorporated parts of the county and the cities of Sebastopol, Cotati, Rohnert Park, Sonoma, Healdsburg, Cloverdale, Windsor, and the Town of Windsor. The cohort provides integrated care management services to individuals with higher needs through IMDT.
- COVID-19-Vulnerable – Focuses on supporting the needs of those most vulnerable to the coronavirus of 2020. These individuals are 65 years or older or have underlying health conditions. Individuals are contacted by outreach and engagement staff at Non-Congregate Shelters and in the community. During outreach, a comprehensive needs assessment is completed. Cohort members are screened for COVID-19 symptoms, educated about COVID-19, and connected to testing and treatment. The team collaborates with individuals and community partners to ensure safe and stable housing as sheltered people transition back into the community.
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