Lake County, a picturesque, rural lakeside community located just north of Napa and Sonoma, has seen a significant drop in tourism due to recent wildfires. Its agricultural industries are still thriving, but government, healthcare and education sectors struggle to fill open positions. Retaining younger, qualified employees for these roles has proven difficult. As a result, the community has many economic and health inequities, leading to a large population impacted by substance use disorder, mental health conditions and high-risk health behaviors. Transportation challenges further exacerbate the situation. In recent years, community leaders and providers have decided to fight back against these trends.

“We want to ensure Lake County is a healthy place for every person to live, learn, engage and thrive,” says Mary Gross, Project Manager for Hope Rising Lake County, an Accountable Community for Health (ACH). “Our ACH convenes community stakeholders and residents to identify and remove barriers that prevent that from happening. Together, we believe collaborative action can improve lives.”

Supported by the ACH’s current backbone organization, Adventist Health Clear Lake, Hope Rising first launched in 2016 and became an ACH in 2017. It has since made a mark on the community with innovative initiatives devised by a coalition of government and education agencies, CBOs, health care organizations and local businesses. Its steering committee has built inter-sector trust through frequent meetings and regular opportunities to collaborate and improve community health. All of their efforts are informed by a Community Health Needs Assessment (CHNA) and Plan powered by community voices, and cultivated with focus groups, surveys and other outreach activities.

One resulting initiative, the Hope Center, a 21-bed transitional housing center, has worked to provide wrap-around care for the community’s most vulnerable unhoused residents. SafeRX, a program to reduce opioid use, has helped thousands of community members prevent, treat and recover from substance use. Both programs’ work has been shaped by the voices of those with lived experience with drug use and homelessness and has been spurred forward by passionate and dedicated staff from the ACH’s partner organizations. Moving forward, Hope Rising is working to increase participation among partners and residents, as well as seek out funding opportunities that can be blended and braided for stronger impact.

To encourage coordination, empower Community Health Workers (CHWs) and fund their efforts, Hope Rising has adopted CalAIM as its key state initiative for the coming years. The CHW Collaborative will help partners utilize the “Pathways Hub” that serves as an information-sharing tool and billing portal. Participating agencies—CBOs, governments, tribal health providers, clinics, hospices and other health care organizations—will ensure warm hand-offs between providers that facilitate better access to transitional/supportive housing, trauma-informed services and assistance in addressing the social determinants of health.

“Our work around CalAIM and our CHW collaborative inspires a more effective, ‘continuum of care’ approach to serving Medi-Cal participants.” says Allen. “Having to repeat traumatic events to multiple providers can be distressing to our vulnerable neighbors. Our developing CHW workforce provides a safe and trauma-informed space to link clients to services. Aligning our ACH work with the CalAIM Population Health Initiative provides an opportunity for us to heal our community and potentially save lives.”

For more information visit www.hoperisinglc.org.