Atlas

POF 02

CalAIM Population of Focus

Homeless with SMI / SUD. The clinic comes to the curb.

Housing-first, harm-reduction, trauma-informed — because a prescription pad is useless without a place to sleep.

About this POF

This population sits at the intersection of CalAIM's Enhanced Care Management, Community Supports (housing), Street Medicine, and Specialty Mental Health / DMC-ODS. Atlas fields multidisciplinary street teams — clinician, LCSW, peer, CHW — that engage members where they are and stay through housing placement and stabilization.

Who qualifies

  • Adults experiencing unsheltered or sheltered homelessness (HUD Category 1 or 4)
  • Serious mental illness diagnosis (schizophrenia spectrum, bipolar I, major depression with functional impairment) OR moderate-to-severe substance use disorder
  • History of avoidable ED use, psychiatric holds (5150/5250), or SUD-related hospitalizations
  • At risk of losing housing, or transitioning out of an interim housing / recuperative care setting

What we do

The full CalAIM toolkit — pointed at one population.

  1. 01

    Street Medicine outreach

    Clinician-led teams round encampments, shelters, and known hotspots weekly — providing wound care, MAT inductions, psychiatric assessment, and hep C / HIV testing on the sidewalk.

  2. 02

    Housing navigation & Community Supports

    Housing deposit, tenancy sustaining, recuperative care, short-term post-hospitalization housing, and day habilitation — the CalAIM Community Supports that turn a plan into a lease.

  3. 03

    Low-barrier MAT & harm reduction

    Buprenorphine on the first visit when clinically indicated. Naloxone, safer-use supplies, fentanyl test strips, and non-judgmental engagement rooted in harm-reduction principles.

  4. 04

    Assertive Community Treatment coordination

    For members with the highest acuity SMI, we coordinate with county Full Service Partnerships and ACT teams so nothing falls through the county / plan seam.

  5. 05

    CARE Act & LPS conservatorship support

    Documentation, court accompaniment, and continuity of voluntary services alongside any court-ordered treatment pathway.

The stakes

Why concentrating care here matters.

187K
Californians homeless on any given night — 68% unsheltered

Source · HUD 2024 AHAR Point-in-Time Count

~30%
Of the unsheltered population reports SMI or SUD

Source · California Statewide Study of People Experiencing Homelessness (UCSF)

27.9 yrs
Average life-expectancy gap for the unsheltered vs. general population

Source · USICH / peer-reviewed mortality studies

Refer a member

Encampment referrals, hospital discharge planners, shelter case managers, first responders, and self-referrals all accepted. No ID, no phone, no address required — we'll help build all of it.

Submit referral(858) 215-6887

For members & families

Enroll yourself or a loved one — we'll walk you through every step, in your language, at your pace.

Become a member

Other populations of focus

Justice-Involved Reentry

Warm-handoff care for adults and youth returning to the community from jail, prison, or juvenile facilities.

Birth Equity (High-Risk Pregnancy)

Doula-supported, culturally-matched care for pregnant and postpartum members at elevated risk of maternal morbidity.