Launch three mobile clinics within high-need areas to improve physical healthcare access.

Enhance access to integrated primary and preventative care.

Implement simplified intake processes to reduce registration barriers by 50% within the first year.

Integrate behavioral health services at 100% of fixed clinic and shelter sites within 18 months.

Vision: Establish a comprehensive, integrated healthcare service model for the under/uninsured homeless population, emphasizing patient-centered care, accessibility, and care coordination.

Mission: Provide compassionate, equitable, and accessible healthcare services that promote well-being and dignity among unhoused individuals.

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Improve health outcomes via holistic, coordinated services.

Increase chronic disease follow-up appointment adherence by 40% using care navigators and EHR tracking.

Establish hospital-to-clinic referral pathways to reduce non-urgent ER visits by 30% over two years.

Reduce disparities and ER usage with sustainable models.

Develop and implement a peer navigator support system to improve patient engagement and continuity of care.

Strategic Plan: Hoshin-Kanri 1.2.1, 1.2.2, 2.1, 2.1.1

Enhance Access to Integrated Primary and Preventative Care

Activity 1: Conduct community needs assessment and mapping of underserved location Resources: Public health analysts, GIS software, community data. Timeframe: Months 1–2

Launch three mobile clinics within high-need areas to improve physical healthcare access.

Activity 2: Acquire and outfit three mobile medical units with necessary equipment. Resources: Capital funding, vendors for medical supplies, maintenance contracts. Timeframe: Months 2–5

Activity 3: Recruit and onboard multidisciplinary outreach care teams. Resources: HR support, salary funding, clinical training materials. Timeframe: Months 3–6

Strategic Plan: Hoshin-Kanri 1.2.1, 1.2.2, 2.1, 2.1.1

Activity 1: Redesign intake forms to reduce documentation requirements. Resources: EHR specialists, policy consultants, legal review. Timeframe: Months 1–2

Implement simplified intake processes to reduce registration barriers by 50% within the first year.

Activity 2: Pilot digital and verbal intake options in mobile and fixed sites. Resources: Tablets/mobile devices, translation services, intake staff training. Timeframe: Months 3–4

Activity 3: Provide cultural competency and trauma-informed training to admin staff. Resources: Professional development budget, trainers, feedback tools. Timeframe: Months 4–6

Activity 1: Recruit and train peers with lived experience. Resources: Outreach networks, training stipends, curriculum. Timeframe: Months 2–4

Develop a peer navigator program to support patient engagement and care continuity.

Activity 2: Assign peer navigators to mobile and clinic sites. Resources: Coordination team, scheduling system. Timeframe: Months 4–6

Activity 3: Evaluate impact on patient retention and outcomes. Resources: Surveys, outcome metrics, peer feedback tools. Timeframe: Starting Month 7, ongoing

Activity 1: Partner with local hospitals and ER departments. Resources: MOUs, liaison staff, workflow agreements. Timeframe: Months 1–3

Establish ER-to-primary-care referral pathways to reduce non-urgent ED visits by 30% in 2 years.

Activity 2: Embed referral navigators in EDs. Resources: On-site staff, orientation protocols, space allocation. Timeframe: Months 3–6

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Activity 3: Monitor ER diversions and primary care follow-ups. Resources: Data analysts, dashboards, reporting tools. Timeframe: Ongoing, starting Month 6

Reduce Healthcare Disparities and Emergency Department Utilization

Activity 1: Develop follow-up tracking protocols in HER. Resources: EHR developers, clinical advisors, templates. imeframe: Months 1–2

Increase chronic disease follow-up adherence by 40% using care navigators and EHR tracking.

Activity 2: Assign care navigators to high-risk patients. Resources: Staffing plan, care coordination software. Timeframe: Months 2–4

Activity 3: Launch reminder calls/texts for follow-ups. Resources: Patient communication systems, contact staff. Timeframe: Months 3–6

Activity 1: Hire behavioral health professionals. Resources: Recruiting team, salary funding, licensing support. Timeframe: Months 2–4

Integrate behavioral health services at all clinic and shelter sites.

Activity 2: Establish co-location and virtual service workflows. Resources: Facility space, telehealth platforms, IT staff. Timeframe: Months 3–6

Activity 3: Train staff in collaborative care and referral processes. Resources: Trainers, manuals, CME incentives. Timeframe: Months 4–6

Improve Health Outcomes via Holistic and Coordinated Services