Neighborhood Networks


Many minors, adults, older adults, and families on Medi-Cal have serious and chronic physical and behavioral health needs. Barriers to critical health resources often cause these individuals to experience health emergencies that land them in hospital emergency rooms but could have been prevented with routine care.


Neighborhood Networks is an innovative program designed to address the health and social needs of community residents using a network of community-based solutions coordinated by highly trained Neighborhood Navigators. The program will serve minors, adults, older adults, and families. Medi-Cal members who struggle with chronic health and/or mental health issues, who have high health care needs, or do not have a place to live may be referred by their health plan to our program.


Navigators provide intensive case management, in-home needs assessments and jointly design a care plan. The program aims to prevent life-threatening events from occurring. Neighborhood Navigators connect clients with direct services and follow alongside the client to ensure all barriers are navigated and routine and preventative appointments take place. Navigators have a long-term service relationship with their clients, addressing their health-related needs by taking a whole person and individualized approach. This can include working with clients on finding local services that will aid with social, financial, medical, behavioral health, housing, education, and employment needs. Navigators follow the client through the web of physical health and behavioral health.

"Working for Lifeline’s Neighborhood Networks program is an opportunity I can greatly learn from; we work as a team to help our clients, this gives me a feeling of enjoyment and accomplishment at the same time. Taking a look at holistic needs is so important for a client’s success. Lifeline really works towards its vision," says Leticia, Neighborhood Navigator.


The program serves minors, adults, older adults, and families who receive medi-cal and who struggle with chronic health and/or mental health issues, who have high health care needs, or who do not have a place to live.  Navigators aim to educate, navigate, advocate, connect, motivate, and support clients, to help improve individual health outcomes. The San Diego Healthcare Quality Collaborative has contracted with Lifeline to provide health-related care coordination to Medi-Cal Recipients. Assessments will be conducted primarily in-home/through telehealth. Based on the results of the assessment, Neighborhood Navigators will connect at-risk clients with direct services. Navigators will have a long-term service relationship with their clients, addressing their health-related needs through connection with social, financial, medical, housing, education, employment, family planning, and other resources.

For more information, please call: (760) 509-3334.  


The program's goal is to improve individual health outcomes by a three-phased approach:
1) Find
2) Treat
3) Measure 

The program also seeks to improve the following outcomes:

  • Finding individuals at risk of poor health outcomes
  • ​Engaging individuals at risk
  • Comprehensive reduction of risks
  • Providing resources and tools to address risks
  • Improve population health
  • Decrease health care costs

"Working for Lifelines Neighborhood Networks program helps clients by empowering them in making their own choices in a nonjudgmental space. It is satisfying to know we are connecting our clients with resources they may have not known about and helping them reach their goals. I feel this program has helped many of my clients in supporting with their physical and mental health," says Linda, Neighborhood Navigator.


Any help for the Neighborhood Network program is a benefit to the program, and the individuals it serves. Donations will be used to assist with wraparound service resources for clients in need. 
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