Coordinating Community Care in the Central Valley

Findings from interviews with safety net providers across the Central Valley, including Calaveras, Fresno, Kern, Kings, Madera, Mariposa, Merced, San Joaquin, Stanislaus, Tulare, and Tuolumne Counties, gathered between July and October 2026.

A regional report prepared by California Coverage and Health Initiatives (CCHI), funded in part by the California Wellness Foundation

READ THE REPORT

Who We Heard From

Area 12 Agency on Aging - HICAP (Health Insurance Counseling and Advocacy Program) ↗ Breaking the Chains ↗ Calaveras County Behavioral Health ↗ Central Valley Immigrant Integration Collaborative (CVIIC) ↗ Centro Binacional para el Desarrollo Indígena Oaxaqueño (CBDIO) ↗ Dignity Health St. Joseph's Medical Center ↗ Easterseals Southern California ↗ Elevate Community Services / RH Community Builders ↗ Family Promise of Greater Modesto ↗ Family Resource Center – 211 San Joaquin ↗ First 5 Tulare ↗ Fresno County Office of Education ↗ Habitat for Humanity Calaveras ↗ Healthy Aging Association / Senior Coalition of Stanislaus County ↗ Kern County Aging and Adult Services ↗ Kern County Public Health ↗ Nancy’s Hope Community Closet ↗ NAMI San Joaquin County ↗ Reading & Beyond ↗ Resources for Independence Central Valley ↗ Sierra Health Foundation ↗ Stanislaus County Health Services Agency ↗ Stanislaus County Community Services Agency (CSA) ↗ Telecare Corporation ↗ The Fresno Center ↗ Tracy Community Connections Center ↗ Turlock Gospel Mission ↗ United Way of Stanislaus County ↗ Vision y Compromiso ↗ West Fresno Family Resource Center ↗ YAI, Inc. ↗

Regional

Priorities

Invest in the organizations already rooted in Central Valley communities.

Support regional infrastructure that makes coordination easier, not more burdensome.

Give communities a meaningful role in designing programs and systems.

Develop and retain the Central Valley workforce needed to sustain services.

California Health Interconnectivity Initiative · Central Valley

Bright spots: where coordination is already working

Across the Central Valley, organizations are already demonstrating what interconnectivity looks like in practice: sustaining coalitions across county lines, building trust, and finding creative ways to sustain shared infrastructure. Filter by category, or click any model to read more.

31 models

Coalitions and shared tables

Healthy Aging Association Senior Coalition of Stanislaus County

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A coalition needs assessment identified transportation as older adults' top priority and helped build the case for Measure L, the county funding measure that now pays for senior transportation.
Coalitions and shared tables

Vision y Compromiso United Against COVID Coalition

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Vision y Compromiso is a statewide organization that supports promotoras and community health workers. Through the United Against COVID Coalition, it helped fill a gap when the local public health department couldn't act on its own, organizing and running vaccine clinics for the community during the pandemic.
Coalitions and shared tables

United Way of Stanislaus County StanCo Health Collab

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A shared table United Way helped stand up with Kaiser, Sutter Health, Valley Children's Hospital, and the county public health department, born out of a first-time joint community health needs assessment and improvement plan. It now holds quarterly meetings bringing together 150 partners to look at population health together. After a recent cut to SNAP benefits, United Way of Stanislaus County raised hundreds of thousands of dollars to distribute grocery gift cards to affected families within five days. They attributed the speed of their response to relationships built through the StanCo Health Collab.
Coalitions and shared tables

First 5 Tulare County Community Care Coalition

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Started during the pandemic, this Tulare County coalition brings together service providers, local government, community-based organizations, FQHCs, and managed care plans to share up-to-date information on health and social services in the county. Coalition leadership comes from the County, First 5 Tulare County, and United Way, and meetings often draw over 100 participants.
Coalitions and shared tables

Fresno County Superintendent of Schools Fresno Cradle to Career

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A decade-long partnership spanning many sectors including education and health, built on a shared community agenda and a continuous improvement network model that participants credit with changes in policy and workflows across participating institutions.
Coalitions and shared tables

The Fresno Center Scale Fresno

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A James Irvine Foundation-funded 26-partner small-business collaboration, including city government, the SBA (Small Business Administration), schools, and nonprofits. Funding for the collaboration keeps otherwise separate agencies engaged with a shared initiative.
Coalitions and shared tables

The Fresno Center Stop the Hate Coalition

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A state-funded, Sierra Health Foundation-administered initiative addressing anti-Asian hate crimes through advocacy, education, and bystander training, run in partnership with other organizations statewide.
Targeted partnerships

Calaveras County Behavioral Health jail-based crisis dispatch

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Places behavioral health staff directly inside the county jail as a dispatch team that also responds out in the community. The program has reduced both hospital visits and time spent in jail for people in crisis.
Targeted partnerships

Elevate Community Services / RH Community Builders Continuum of Care performance alignment

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Aligned its own county service contracts with the Fresno-Madera Continuum of Care's system performance measures, allowing for a shared, outcomes-based way to compare progress across separate contracts. A Continuum of Care (CoC) is the local or regional planning body that coordinates homelessness services and funding in a geographic area, typically including nonprofits, local governments, housing providers, and other partners, tied to HUD's (U.S. Department of Housing and Urban Development) Continuum of Care program.
Targeted partnerships

Family Promise of Greater Modesto on-site transitional housing

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Opened its first on-site transitional housing program in November 2024 and has since moved 30 families into permanent housing.
Targeted partnerships

Family Promise of Greater Modesto Early Head Start partnership

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An on-site partnership with the Stanislaus County Office of Education provides childcare for close to 220 children under age three, so parents can keep working while the family stabilizes.
Targeted partnerships

Habitat for Humanity Calaveras home building and repair pipeline

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Grew from three staff to eleven in about three years and is on track to build over 100 homes, alongside roughly dozens of home repairs and several neighborhood revitalization projects.
Targeted partnerships

Tracy Community Connections Center cross-sector data sharing

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Maintains data-sharing MOUs with the local police department and area shelters, and long-standing referral relationships with landlords, recuperative care facilities, and sober living homes, as the only nonprofit homeless services provider in Tracy.
Targeted partnerships

Turlock Gospel Mission family shelter expansion

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Local churches repurposed office space into private family shelter rooms, including space for single fathers with children, in response to rising family homelessness.
Targeted partnerships

Kern County Public Health Childhood Illness and Injury Prevention Program

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Brings together local school districts, the Bakersfield Police Department, and the California Highway Patrol around car seat and pedestrian safety, integrating lead poisoning prevention and dental programs and reaching parents through schools. The department noted that these law enforcement partners had not historically worked with school districts.
Targeted partnerships

Kern County Public Health emergency room HIV and STI testing

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A program that offers HIV and STI testing when individuals come into the emergency room to help address high local rates and connect people with treatment. Expanding beyond a single hospital has also strengthened communication with staff at partner organizations.
Targeted partnerships

First 5 Tulare County CASA and juvenile court collaboration

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After meeting with the juvenile judicial council about how to make better-informed decisions for detained young children, First 5 brought in CASA (Court Appointed Special Advocates), since most children ages 0 to 5 are assigned a CASA advocate. Partners determined that advocates could include more of the information judges were seeking in their reports.
Targeted partnerships

CBDIO and UCSF Fresno mobile health clinics

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A partnership between Centro Binacional para el Desarrollo Indígena Oaxaqueño (CBDIO) and UCSF Fresno, in place since 2021, that brings UCSF Fresno's mobile health clinics to rural parts of Fresno County. By pairing clinical services with a trusted community organization, the collaboration aims to reach residents who may face barriers to care, including distance, transportation, and language.
Data and referral infrastructure

Family Resource Center – 211 San Joaquin Coordinated Entry System

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Has served as the lead entity for San Joaquin County's Coordinated Entry System, funded through HUD, for several years, running bilateral, closed-loop referrals through its 211 line.
Data and referral infrastructure

Family Resource Center – 211 San Joaquin San Joaquin Children's Alliance

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Helped found this cross-sector coalition in 2013 as a dedicated, funded "backbone" organization focused on children and family services across the county.
Data and referral infrastructure

Area 12 Agency on Aging HICAP emergency evacuation registry

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Maintains a county-registered system for evacuating older adults and people with disabilities during emergencies, so the county has advance notice of who needs extra help. During a recent regional fire, the system helped ensure evacuees' medical information and Medicare cards weren't left behind, and the organization takes part in search teams that run regular multi-hazard evacuation trainings (fire, flood, warming/cooling stations).
Data and referral infrastructure

Kern County Aging and Adult Services H.R. 1 coordination meetings

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Began holding regular, more formalized meetings with managed care plans and county partners this year in response to H.R. 1-driven changes.
Data and referral infrastructure

Reading & Beyond SDOH screening and referral

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Community health workers use a standardized social drivers of health questionnaire to identify what clients need beyond the program they walked in for, then connect them directly to outside services, catching gaps a single-program intake wouldn't surface.
Data and referral infrastructure

Resources for Independence Central Valley voter accessibility workshops

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Its community organizer works directly with the Fresno and Tulare County clerks' offices to run workshops before elections, letting people with disabilities practice with voting equipment ahead of time.
Data and referral infrastructure

Fresno County Information Exchange

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FCIE is a shared data system that links education data with public health and social services data, so schools, health providers, and county agencies can coordinate care for the same children and families. The County of Fresno and the Fresno County Superintendent of Schools jointly lead the effort, with investment from Fresno County. Its first pilot focuses on youth suicide prevention, combining data from partner agencies to identify young people at risk and connect them to support sooner.
Community trust and belonging

Breaking the Chains City Center co-location

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Breaking the Chains operates out of Fresno's City Center, a shared building that houses multiple CBOs in the same building. Breaking the Chains credits this co-location with much of the day-to-day collaboration that occurs among the city's anti-trafficking and homelessness service providers.
Community trust and belonging

West Fresno Family Resource Center Transformative Climate Communities

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A state-funded Strategic Growth Council program in which the organization led community voting on local projects, successfully securing funding for the projects Southwest Fresno residents chose.
Community trust and belonging

Nancy's Hope Community Closet Food Shift Program

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Recovers surplus produce from local farms and restaurants that would otherwise go to landfills and redirects it to its food pantries.
Community trust and belonging

Nancy's Hope Community Closet Back-to-School Shopping Program

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A partnership with the Tuolumne County Superintendent of Schools takes 10 to 12 at-risk kids back-to-school shopping for new clothes and shoes each year.
Community trust and belonging

CBDIO Labor Justice Team

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Centro Binacional para el Desarrollo Indígena Oaxaqueño (CBDIO) provides training, education, and resources so community members can advocate for themselves against wage theft.
Community trust and belonging

NAMI San Joaquin County Provider Class

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A regular class that helps providers in mental health and medical fields understand the perspective of family members and peers, including how to listen to families even when privacy rules limit what providers can share.