Sacramento County’s mobile clinic is doing more than just rolling into neighborhoods, it’s rolling out a whole new level of care. Wellness Without Walls (W3), the County’s mobile health program, has added Behavioral Health Services’ Homeless Engagement and Response Team (HEART) to its network, bringing mental health and substance use services directly to people experiencing homelessness or housing instability. This expansion is helping W3 deliver whole-person care all in one stop.
HEART staff, which include master’s level clinicians and peers with lived experience, now co-deploy with W3 in the field and to local shelters to provide behavioral health screenings, treatment referrals and ongoing case management. They’ve already begun distributing Narcan and fentanyl test strips and have been working side by side with W3’s medical staff to reach individuals where they are. By blending physical and behavioral health services into one visit, the effort is not only increasing access but also reducing the stigma around asking for help.
“HEART is very excited about this collaboration,” said Monica Rocha-Wyatt, Health Program Manager. “In order to address the health needs of the homeless population, you have to address the whole person, both physical and behavioral health. Including a BHS screening as part of overall health services also removes some of the stigma that still exists regarding mental illness and substance use. Making this full menu of services available makes it more convenient and more likely individuals will take advantage of the services.”
W3 began as a collaboration between divisions of the Department of Health Services, Public Health and Primary Health, in 2022, with support from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC). Public Health leads sexual health efforts, offering HIV and STI testing, education and referrals. Primary Health operates the mobile clinic and delivers services like wound care, medication and chronic disease management. The idea is simple: if people can’t get to a clinic, the clinic should come to them.
Since its launch, W3 has grown into a full-scale outreach effort thanks to the support of community partners like Loaves and Fishes, First Step Communities, Community Health Works and UC Davis’ School of Nursing. Local organizations and businesses, from pharmacies to pet wellness services, have also helped expand services and meet the diverse needs of patients in the field.
Bringing HEART into the mix adds a crucial layer to W3’s mission. Many people served by the mobile unit are managing co-occurring conditions like depression, trauma or substance use but may not know where to turn. With HEART onboard, patients can now receive behavioral health care on the spot, alongside their physical care, making it easier to begin the process of recovery and healing.
The results speak for themselves. W3 has already served hundreds of individuals, reconnecting some with HIV care, helping others begin Hepatitis C treatment and supporting people through housing transitions and benefit navigation. But beyond the medical outcomes, the true measure of success is trust. Patients return. They recognize the staff. They open up. And they take that first step toward stability, often because someone met them exactly where they were.
“Even though the effort only recently launched, the potential is obvious,” said Monica. "Individuals experiencing homelessness are not refusing services. Traditional services are too hard to access for people without reliable transportation, those afraid to leave their encampment and their belongings, or those who have to go to multiple locations for care, etc."
W3 staff say the HEART collaboration has been a natural fit and each division is learning from the others. Everyone shares the same goal: to make care easier, not harder, for people in crisis.
While the program is still growing one thing is clear, W3 is on a roll and the road ahead looks promising.
“I hope this new partnership sets an example of what can be done through collaboration,” said Monica. “Long gone are the days of siloing services; the culture has shifted to collaborating and combining efforts for more efficient and easier to access services.”