When most Californians turn their attention to San Diego, they tend to envision a beautiful seaside playground, with picturesque coastlines, cool breezes, beachside dining and theme parks around every corner. While much of that is true, San Diego County’s patchwork of communities is much more interesting and diverse, with rural farmlands, urban centers, sleepy inland suburbs, multicultural border communities and pockets of poverty nestled in between wealthy enclaves.

“With one of the most expensive real estate markets in America, many San Diegans are just barely making ends meet,” says Cheryl Moder, Vice President of Collective Impact and Communications for the San Diego Wellness Collaborative, an Accountable Community for Health (ACH). “The county’s 18 cities and many tribal communities are home to over 3.3 million residents—and nearly one-third of them are insured by Medi-Cal.”

With a large Latino, refugee, and low-income population, language barriers, distrust in institutions and limited health care resources often stand in the way of services that address the social drivers of health and promote wellness.

“That’s why we came together to form the San Diego Wellness Collaborative,” continues Moder. “It was clear we needed to develop a wellness system where all communities have access to health. We’ve made that happen by establishing multi-sector community-clinical linkages that transform the health system to include far more stakeholders than just health care providers.”

The collaborative, which began with a focus on cardiovascular health, eventually blossomed into a much more ambitious effort. Stakeholders from community-based organizations (CBOs), health systems, public health, academia, philanthropy and other sectors realized that health equity is much broader than any one issue. It can also include housing access, food security or social connectedness—not just access to basic health care services.

Today, this effort has centered around Neighborhood Networks, a social enterprise that serves as a hub to support CBOs in delivering CalAIM services. This new community-based workforce provides Enhanced Care Management (ECM), Housing Navigation, and Community Health Worker (CHW) services to Medi-Cal members. Revenue from Neighborhood Networks now helps to support ACH backbone efforts.

Since 2022, over 1,200 individuals with complex physical, mental or behavioral health needs have been served by Neighborhood Networks partners. In addition to providing in-home visits and coordination among service providers, Neighborhood Networks helps participants find doctors, make appointments, access transportation and apply for public benefits like CalFresh, WIC, SSI and legal aid.

Through its Housing Navigation services, Neighborhood Networks has distributed over $160,000 in Medi-Cal funds to provide rental deposits and help participants move into stable homes. Additional funding, through the BUILD Health Challenge, fuels a partnership with the San Diego Refugee Communities Coalition, a group of over a dozen ethnic CBOs. Together, the ACH and the coalition work to increase housing security and address housing disparities among refugee communities.

“As one of a few mature hub organizations in the United States, we’re blazing a trail for communities statewide and learning what works—and what does not,” says Moder. “We’re now helping ACHs across California adopt models like ours. Some technical assistance combined with time-tested best practices can go a long way toward transforming communities.”

Learn more at sdwellnesscollaborative.org.