As a care manager, hospital discharge planner, or health plan coordinator in Solano County, you are on the front lines of a healthcare crisis. You witness firsthand the revolving door of emergency room visits, the cycle of readmissions, and the immense struggle of patients whose complex health needs are compounded by homelessness, substance use, mental health challenges, and recent incarceration. You know that traditional healthcare models often fall short for these individuals, leaving them—and you—feeling frustrated and powerless.

You need a partner who can step into the breach. A partner who can go beyond the clinic walls, meet patients where they are, and address the real-world barriers preventing them from achieving wellness. You need a partner who doesn’t just offer services, but offers hope.

Solano Impact Care is that partner. We specialize in providing intensive, community-based care coordination for the most vulnerable Medi-Cal members in Solano County. This article will explain how our unique approach to whole-person care in Solano County saves lives and how you can seamlessly refer your most complex patients to us.

Who We Help: A Lifeline for Your Most Complex Patients

Our services are designed for individuals facing multiple, intersecting challenges. If you have a patient who is a Partnership HealthPlan or Kaiser Medi-Cal member in Solano County and is experiencing any of the following, they are likely a perfect candidate for our support:

• Facing Homelessness or Housing Insecurity: Individuals who are currently homeless, at risk of losing their housing, or living in unstable conditions in cities like Vallejo or Fairfield.
• Frequent Hospital or Emergency Room Use: Patients with a pattern of high utilization of emergency services or multiple hospital readmissions for conditions that could be managed in the community.
• Recent Release from Jail or Prison: Individuals transitioning back into the community after a period of incarceration, who often lack housing, employment, and healthcare connections.
• Struggling with Substance Use Disorders: People in any stage of their recovery journey who need consistent support to maintain sobriety and access treatment.
• Serious Mental Health Concerns: Individuals with significant mental health conditions that impact their ability to manage their daily lives and health needs.
• Complex Chronic Health Conditions: Patients juggling multiple chronic illnesses who struggle with medication adherence, appointment scheduling, and navigating the healthcare system.
• Transitioning from a Skilled Nursing Facility: Individuals moving back into the community who require a robust support system to ensure a safe and successful transition.

We understand that these individuals require more than a 30-day care plan. They need a dedicated team that understands their trauma and can build a foundation of trust. That is the core of our community care management model.

How It Works: A Seamless Referral Process for Partners

We know your time is valuable. Our goal is to make the ECM referral process in Solano as simple and efficient as possible, ensuring your patients get connected to care without delay.

Step 1: Identify a Potential Client 

Review your caseload for patients who fit the criteria listed above. Think of the individuals who consume a disproportionate amount of your time and resources, yet continue to experience poor health outcomes. These are the people we are built to serve.

Step 2: Make the Referral 

To initiate a referral, you have two simple options:

• Call Us: Dial (707) 301-4051 to speak directly with our intake team. We can take all the necessary information over the phone.
• Email Us: Send an email to care@solanoimpactcare.org with the patient’s information and a brief description of their situation. Our team will promptly follow up with you.

We will handle the benefits verification and eligibility confirmation with Partnership HealthPlan or Kaiser.

Step 3: The Warm Handoff

Once the referral is accepted, we immediately begin our engagement process. A member of our team—a Care Manager with lived experience—will reach out to the individual. We don’t wait for them to come to us. We go to them, whether they are in a shelter, a hospital bed in Fairfield, or a temporary living situation in Vallejo.

Step 4: Comprehensive Assessment and Care Planning

Our team conducts a thorough, in-person assessment that goes far beyond a medical history. We seek to understand the whole person, including their history, their strengths, and their goals. This assessment directly addresses the social determinants of health in Solano that are impacting their life. Based on this, we develop a collaborative care plan that is client-centered and action-oriented.

Step 5: Ongoing Collaboration and Communication

We view our referral partners as essential members of the care team. You will receive regular updates on your patient’s progress. We are committed to open communication and a collaborative approach to ensure we are all working together to support the client’s journey toward stability and health.

What Makes Us Different: The Power of Lived Experience

Many organizations offer care management. What sets Solano Impact Care apart is our people. Our team is comprised of individuals who have personally navigated the very systems our clients are struggling with. They have experienced homelessness, incarceration, and the challenges of recovery. This isn’t just a job for them; it’s a calling.

This “lived experience” model is our superpower. It allows us to:

• Build Trust Instantly: Our clients see themselves in our team members. The walls of distrust and fear come down, replaced by a sense of understanding and hope.
• Navigate Systems from the Inside Out: Our team knows how to cut through red tape because they’ve had to do it for themselves. They know the people, the processes, and the shortcuts to getting things done.
• Provide Trauma-Informed Care Authentically: We don’t just talk about being trauma-informed; we live it. Our approach is rooted in empathy, patience, and a deep understanding of how trauma impacts a person’s ability to trust and engage.

This is the cornerstone of our community care management model. It’s about human connection first, services second. This is how we achieve health equity for Medi-Cal members—by leveling the playing field and giving everyone a fighting chance.

The Impact of Whole-Person Care in Solano County

When we address the social determinants of health in Solano, we do more than just improve health outcomes; we transform lives and communities. By providing care coordination for vulnerable populations, we are breaking the cycle of crisis and creating a pathway to long-term stability. For our partners in hospitals and health plans, this means:

• Reduced Readmission Rates: By providing robust support after discharge, we ensure patients have the resources they need to recover safely at home.
• Lower Emergency Department Utilization: We help clients manage their chronic conditions proactively, reducing the need for crisis-level care.
• Improved Medication Adherence: Our teams provide reminders, education, and help with refills, ensuring clients stick to their prescribed treatment plans.
• Better Health Outcomes: By addressing housing, food insecurity, and other barriers, we create an environment where health and wellness are possible.

Understanding ECM: A Pillar of the Community Care Management Model

While we lead with the human element, it’s also important for our partners to understand the framework we operate within. The services we provide are known as Enhanced Care Management (ECM) and Community Supports, which are key components of California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative.

• Enhanced Care Management (ECM): This is the high-touch care coordination for vulnerable populations that forms the core of our work. It’s a collaborative, community-based approach that assigns a dedicated, single point of contact to help individuals manage their complex health and social needs.
• Community Supports: These are 14 specific services designed to address the social determinants of health. They include things like housing navigation, medically tailored meals, and support for individuals transitioning from institutions. Solano Impact Care connects our clients to these vital resources.

CalAIM is California’s bold move toward health equity for Medi-Cal members, and our work is a direct implementation of that vision. We handle the complexities of the system so you can focus on what you do best: providing excellent clinical care.

Conclusion

Care coordination isn’t just a service — it’s a lifeline. For Solano County’s most vulnerable residents, having a dedicated team to navigate complex systems can mean the difference between crisis and stability. When housing, healthcare, and social support work together, people don’t just survive — they thrive.

Referring someone is simple, and the impact is profound. Whether you’re a provider, a neighbor, or a family member, you have the power to connect someone to the help they need. Don’t wait for the perfect moment. Make the referral today — because in Solano County, no one should have to face their hardest days alone.