The Northern Sonoma County Coalition: Strengthening our System of Care Through Unity and Mutual Aid

What happens when you bring a foundation and nonprofits together with the goal of increasing sustainability and strengthening the system of care? What can happen when a foundation facilitates coordination among expert organizations to this end?

These were the questions that inspired, and continue to guide, the Northern Sonoma County Coalition, which the Healthcare Foundation initiated in January. 

But first a little background: In January of 2022, the California Department of Healthcare Services launched California Advancing and Innovating Medi-Cal, or CalAIM, a multiyear initiative to improve health outcomes for those living with complex health and social needs. For the first time in history, social determinants of health services such as case management, housing navigation, rental assistance, medical case management, caregiving, food distribution, and transportation became reimbursable through Medi-Cal insurance.

This expanded coverage is having an important impact for providers and the communities they serve across the state—as a major new report channeling the voices of Californians with multiple health and social needs makes clear. (You can read key takeaways as well as the report itself by visiting California Health Care Foundation’s website.)

Locally, this means that our region’s clinics and nonprofits providing this vital care can be reimbursed for their work. 

Yet, while the program itself is a huge step forward in expanding healthcare, the preparation to become a CalAIM provider is a long and complicated road requiring a potentially significant investment of time and resources. This is especially true for northern Sonoma County’s impactful but smaller grassroots organizations and healthcare clinics. 

This is why we formed the Northern Sonoma County Coalition. It brings together the six organizations that make up our region’s system of care, all of whom are technically eligible to bill Medi-Cal for services but, to varying degrees, face hurdles in attaining status as a CalAIM provider. Through coordination and the pooling of collective knowledge and resources, the Coalition seeks to help each member with the institutional lift, ultimately clearing the way for a sustainable revenue stream that can help offset operational costs, strengthening each organization and our system of care as a whole.

“It’s all been a reminder of how fortunate we are to live and work in northern Sonoma County, where a sense of common purpose and solidarity with our neighbors can make small organizations into a mighty collective.”

Amy Ramirez, Executive Director

Our Coalition’s member organizations were all at different places with respect to CalAIM billing practices when we launched in January of 2025, with some already moving toward integration in the system and others feeling that they could never achieve the goal of becoming a CalAIM provider. 

We set an ambitious goal of supporting all six organizations in becoming CalAIM providers by the end of 2026, and we are well on our way with each of the six organizations now moving full speed ahead. 

While the initial goal of the Coalition was and remains to provide support, connections, training and funding to support their CalAIM work, along the way we have discovered the incredible impact of collaboration more generally: Our Coalition members are learning from each other, forming deeper connections, coordinating communication and referral channels (to ensure a smooth process for their clients and patients), and engaging in collaborative grant writing.

Not to mention the impact on morale of our time together, which has been both energetic and truly supportive.

It’s all been a reminder of how fortunate we are to live and work in northern Sonoma County, where a sense of common purpose and solidarity with our neighbors can make small organizations into a mighty collective capable of creating sustainability and best practices in service to the community we love. I have no doubt that the success of the Northern Sonoma County Coalition will also serve as a blueprint for foundation-supported coalition work in other communities.