Update and reprocure Community Care Coordination (C3) and Housing programs

Lead agency: Health and Human Services Agency

Population of focus (if applicable): Justice-involved individuals transitioning from custody, including special populations such as veterans with high health and housing needs and those with shorter jail stays and high needs. May also include those with repeated justice involvement/outstanding criminal legal matters and high needs in the community.

SIM intercept: 2-3, 4-5

Summary of planned action:  

Redesign and reprocure existing community care coordination services to leverage Medi-Cal Enhanced Care Management and Community Support Services. Identify referral pathways for special populations such as Veterans (e.g., from custody) or individuals with high health needs (such as serious mental illness/co-occurring disorder) while also broadening eligibility to individuals at risk of continued justice involvement because of multiple unmet needs and homelessness

Actions taken: 

  • The Community Care Coordination (C3) programs have added a valuable service to San Diego County’s service landscape, espousing a long-term care coordination and housing model that incorporates peer specialists, clinicians, and housing specialists to provide whole-person services over a period of up to 12 months. These programs serve justice-involved individuals who are at-risk of or experiencing homelessness. The C3 teams use a trauma-informed approach to provide intensive in-reach and outreach engagement activities (in and out of custody) to build trust and rapport to reduce poor outcomes, homelessness, and barriers to accessing services. 

  • Currently, the County has two active C3 programs, C3RES—a program for individuals with behavioral health conditions, and ATI C3, a care coordination program that focuses on individuals who cycle in and out of jail quickly or at risk of future arrest. Other C3 programs such as the first C3 program and C3 Straight to Home have ended because they were grant funded, C3V (C3 for veterans) was County funded, but also recently ended due to lack of a sustainable funding source, and C3RES is expected to sunset at the end of January 2027 after grant funding is fully spent.  

  • Additionally, due to the high-touch service that is provided to participants, only a limited number of individuals can benefit from these programs. All partners involved have affirmed that sustaining these services is a priority. Therefore, it is necessary to redesign and reprocure these services in a way that ensures they are sustainable and accessible to more justice-involved individuals. This ATI action intersects with other ATI proposals, such as implementing more effective upstream interventions to prevent justice-involvement, increasing enrollment into Medi-Cal pre-release, and providing options for pathways after custody for those who do not receive comprehensive reentry planning while in Sheriff’s custody.

  • County health and justice partners have prepared an updated Statement of Work (SOW) for a community care coordination program to assist high-needs populations at the point of release from custody. The new SOW builds on the design of the County’s Community Care Coordination (C3) programs, but seeks to leverage funding for case management, transitional housing, and other supports for justice-involved individuals, veterans, and homeless populations, as well as those with high needs, including medically complex or behavioral health conditions and serious mental illness under Medi-Cal. The SOW also aims to broaden access to the program by asking providers to accept clients referred by County reentry staff or justice partners who assess them during a longer jail stay, and individuals who self-refer or seek help without a prior assessment or hand-off, including clients in jail a short time and released without service connections. An Industry Day and a written Request for Information informed the design of the new SOW. 

Next steps: 

  • The solicitation is expected to be posted on BuyNet by April 2026, with services in place in 2026. 

  • Monitor program for

  • Equity in use of these services (demographic data).

  • Effect of services on recidivism to jail or entry into jail. 

  • Effect of services on participant stability re: housing, health, employment, and social supports. 

  • Economic analysis of a mixed funding model and evaluation of long-term sustainability (through ability to leverage Medi-Cal for core care management and community supports services, including rental assistance).