We Care for Your Organization’s Members Like They Are Our Own
We know the members of your congregation or organization feel like your own family. You want the very best for them. Heritage Health Network partners with local CBO and Faith Based organizations to help individuals and families overcome medical, behavioral, and social barriers to health. By connecting people to vital resources, coordinating care, and providing compassionate support, we empower communities to thrive.
How HHN Supports Your Practice
We can help support members in your organization that may be struggling to navigate health and social challenges, lack access to vital services and wish to gain stability to thrive. Just some of the organizations we are partner with include:
Community-Based Organizations
Faith-Based Organizations
Health Plans
Homeless service providers
Food pantries and shelters
Behavioral health agencies
Schools and youth programs
Re-entry and justice organizations
Why CBOs and Faith Based Organizations Embrace HHN
- Proven Infrastructure: HHN already has secure referral networks, reporting systems, and trained care teams in place, allowing organizations to plug into a ready-made system instead of starting from scratch.
- Deep Case Management Expertise: HHNHealth Network specializes in Whole Person Case Management and understands how to align community efforts with Medi-Cal and managed care requirements.
- Community-Centered Approach: Our model is built around local trust. We don’t replace the role of community organizations — we amplify it by giving them the tools, training, and data systems they need to succeed.
- Trauma-informed, culturally and linguistically relevant- We design care that truly reflects the heartbeat of each community—meeting members where they are, honoring who they are, and walking beside them on their path to stability and wellness.
How Can Help Serve the Members of Your Organization
- Connection to medical and behavioral health care
- Help with housing, food, and transportation
- Support after hospital discharge
- Coordination with county and local resources
- Assistance applying for Medi-Cal or Medicare benefits
- Education on chronic conditions and medications
- Emotional and spiritual support in collaboration with faith partners
Want to learn more about how we can impact your organization specifically?
Populations of Focus
HHN focuses on the seven DHCS-defined Populations of Focus (POFs) under the CalAIM Enhanced Care Management program. These are Medi-Cal members facing the most significant barriers to health and stability.
| # | Population of Focus (POF) | What This Means | How HHN Helps |
|---|---|---|---|
| 1 | Individuals & Families Experiencing Homelessness | People without stable housing, living in shelters, cars, or doubled-up. | Connect to housing programs, food access, transportation, and health care. |
| 2 | High Utilizers of Emergency & Inpatient Services | Members with frequent ER visits or hospitalizations from unmanaged conditions. | Coordinate chronic-care management, medication support, and post-discharge follow-up. |
| 3 | Individuals with SMI or SUD | Adults with significant behavioral-health needs impacting daily life. | Link to therapy, psychiatry, recovery programs, and community behavioral-health care. |
| 4 | Individuals Transitioning from Incarceration | People leaving jail, prison, or juvenile facilities and re-entering the community. | Provide re-entry navigation, medical linkage, housing aid, IDs, and medication continuity. |
| 5 | Individuals at Risk of Institutionalization | Adults or seniors with functional decline who may require facility placement. | Coordinate in-home services, home health, caregiver support, and community resources. |
| 6 | Children & Youth with Complex Needs | Children under 21 with physical, behavioral, or developmental challenges. | Coordinate pediatric, behavioral, and social services while supporting families. |
| 7 | Pregnant & Postpartum Individuals at Risk | Expectant/new mothers facing medical, social, or racial disparities. | Provide prenatal/postpartum support, OB linkage, housing, nutrition, and mental-health care. |
If your organization is serving similar populations - lets work together. These are our neighbors — mothers, fathers, veterans, youth, and seniors — facing barriers no one should face alone.
Together, we can build a stronger, healthier community — helping your members reach their full potential.
Getting Started
We realize the needs, goals and challenges of every CBO / Faith Based Organization are unique. Our process is clear but considers your specific mission.
Onboarding
Receive your Partnership Onboarding Package to authorize collaboration and begin coordinated support with HHN.
Identify High-Need Members
Identify Members in your organization needing added support and securely share their information with HHN for coordination.
HHN Engages Patients
Our team connects with your Members, schedules needed appointments, and helps remove common barriers to reaching wellness goals.
HHN Tracks Outcomes
Quarterly reports give updates on Member progress, identify improvement needs, and support your organization’s care goals.
Let’s explore how we can work together to close gaps in care and create healthier communities.
Reach out today to start the conversation.
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