Outreach Department Services List

The following is a general list of services that Community HealthWorks’ Outreach teams can provide to individuals experiencing homelessness. If there is a service need that is not listed, we are open to discussing adding it to our menu of services.

CalAIM Referrals for ECM (Enhanced Care Management) and CS (Community Supports).

  • ECM: Gives the client a case manager who will oversee their medical needs. This includes establishing primary care, scheduling and attending medical appointments, and scheduling medical transportation.
  • CS: Gives the client a case manager who will assist them in pursuing permanent housing. This program will also cover move-in costs and in many cases furniture costs once suitable housing is found.

Permanent Housing Services

  • PSH (Permanent Supportive Housing): Housing that is for clients who are chronically homeless (1 year or longer) and have a disability. CHWs will complete necessary paperwork with the client to get them on waitlists and provide case management until the client moves in.
  • Family Reunification: If a client has a family member or friend who can house them but needs assistance with the transportation to get to this location (including out of state), Community HealthWorks can assist by paying for a bus or plane ticket so long as we have confirmation from the family/friend who will be housing the client.
  • RRH (Rapid Re-Housing): Permanent housing specific to clients who have sufficient income or who could get more hours working if they had a stable place to live.
  • Market Rate Housing: If a client has sufficient income and just needs help with the process of searching for a place to live and paying for application fees and deposits, then Community HealthWorks can assist them.

Emergency Shelter Services

  • CAS Assessments: Performing shelter assessments in HMIS to get clients on waitlists for shelters within the Coordinated Access System.
  • Geographical Shelters: Performing outreach and screening for shelter partners who house clients in specific geographical areas.
  • Direct Shelter Referrals: Coordinating with shelter partners as opportunities arise to assess for eligibility, perform referrals, and transport clients to shelter intake appointments.

Medi-Cal Services

  • New enrollment.
  • Transferring benefits from another county.
  • Medi-Cal renewal.

Social Security Cards/Benefits

  • Assisting clients with social security card applications. Scheduling appointments to get them transportation and attending the appointment with them.
  • Calling social security to apply for benefits.

DMV Vouchers and Appointments

  • Completing DMV vouchers with clients.
  • Scheduling transportation and assisting clients through the paperwork process of getting their ID.

Welfare office visits

  • Assisting clients with applying for CalFresh or other benefits.
  • Assisting clients obtain replacement benefit cards.


  • CHWs can schedule transportation (via Lyft) for clients for any social services or housing related appointments as long as the client is enrolled in the correct HMIS program, and our CHWs are able to create a Salesforce profile for the client internally. We are unable to transport clients for medical appointments unless the goal is to get a disability certification for housing.