By HC² Strategies Team: Community Impact Director Rebecca Brandes, Project Manager Megan Gutierrez, Chief Transformation Officer Lauran Hardin, and Chief Integration Officer Niñon Lewis

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Older adults experiencing homelessness represent one of the fastest-growing and most vulnerable populations in San Bernardino County, California. The combination of aging, changing social support structures, chronic health conditions, and housing instability compounds risks to health and well-being, creating an urgent need for coordinated, whole-person care. In Western San Bernardino County, a cross-sector, multidisciplinary team is working to address this growing issue. The Community Care and Housing Solutions for Aging Adults (CCAHSAA) “Collaboratory” is building a Connected Community of Care to support older adults experiencing homelessness or persistent housing insecurity.

Communities facing the greatest challenges for their residents—the uninsured, children and families in the foster care system, and individuals experiencing behavioral health, substance use, homelessness, or high care needs—often look to collaborate across sectors to develop holistic and effective solutions. However, while community stakeholders are often skilled at collaborating within their own sectors, cross-sector partnerships present unique challenges, such as differing objectives, language, metrics, governance structures, and data systems; siloed funding streams; or care delivery improvements that aren’t aligned with system-level improvements.

To build a Connected Community of Care, a multi-stakeholder collaboration follows six steps:

1. Define their focus
2. Convene leadership structures
3. Explore data and choose a population of focus
4. Build and implement a portfolio of interventions and investments
5. Plan for sustainability of relationships, processes, structures, and financing of the effort
6. Celebrate successes and harvest learnings

This effort emerged from conversations within the West Valley Regional Steering Committee (as part of the San Bernardino County Continuum of Care) and a connection to the opportunity for funded coaching from HC2 Strategies through the California Health Care Foundation. At its inception, three major activities took place: defining the focus, convening leadership structures, and exploring data. The CCAHSAA Collaboratory has since built a portfolio of interventions, and along the way has centered planning for sustainability, celebrating successes, and harvesting learning.

Defining the Focus

In March 2025, a cross-sector, multidisciplinary group of local champions convened as an initial Design Team to set the vision, goals, and portfolio of interventions for the Collaboratory. Together, they imagined what a Connected Community of Care would look like in the region and local systems of care.

The group determined the specific area of focus for the work and prioritized the population of focus to older adults experiencing homelessness or persistent housing instability.  Finally, the Design Team co-designed a set of high-leverage strategies and outcome measures that would have the most impact based upon a review of evidence-based practices and bright spots from other communities around the United States.

Convening Leadership Structures

An initiative of this nature requires strong, dedicated local leaders. At the heart of this project is Don Smith, a Senior Program Consultant at Inland Housing Solutions and Co-Chair of the West Valley Regional Steering Committee, who brings many years of experience working to address homelessness and established relationships across the system of care. He has served as the catalyst for this work and chair of the CCAHSAA Collaboratory.

The Design Team transitioned to become the Collaboratory’s Leadership Group, setting the Collaboratory vision, overseeing progress and measurement, and rebalancing the portfolio of interventions when needed. One of the key success factors of this group is the intentional inclusion of cross-sector partners including homeless response, city, county, health system, managed care plan, community-based providers, and the faith community.

As leadership structures and roles evolve, the Collaboratory has moved into action-oriented workgroups advancing specific interventions, and local leaders have emerged to bring deeper connections, intentionality, and sustainability to the work.

Exploring Data & Choosing a Population of Focus

A vital part of building a Connected Community of Care is gaining a deep understanding of the target population through quantitative and qualitative data. After choosing the population of focus, the Design Team embarked on the journey of conducting a landscape analysis adapted from the Three-Part Data Review model—utilizing existing quantitative data to identify overall patterns for the population, engaging with providers that serve the population, and interviewing individuals with lived experience.

Through this process, data was obtained from several local sectors, including the Homeless Management Information System (HMIS), 211 and Coordinated Entry System (CES), hospitals and health systems (volunteered aggregate data, HCAI data via SpeedTrack, and local Community Health Needs Assessments), community-based organizations (CBOs), and cities. Key informant interviews were conducted with over 20 local providers and individuals with the lived experience of homelessness in San Bernardino County. The voices of those individuals crystallized the needs that the Collaboratory would address, including comments such as these.

Landscape Analysis Key Findings:

• An estimated 945 residents aged 55 and older are experiencing homelessness on any given day in San Bernardino County, accounting for nearly one in four unhoused individuals countywide (per the 2025 PIT Count)
• The current system can be “fragmented” and reactive—sometimes offering help “a little too late.”
• Compassion and dedication among providers is an asset to the system and clients’ experience
• Gaps in housing, long-term supports, and system navigation persist

Building and Implementing a Portfolio of Interventions and Investments

Additional work from the group narrowed the population of focus to older adults over the age of 50 experiencing homelessness or persistent housing instability. This change focused their efforts on preventing homelessness, including benefits available across the aging life course, and inviting a wider net of potential partners and supports available to older adults in western San Bernadino County.

Based on the high-leverage strategies initially chosen by the Design Team, the CCAHSAA Collaboratory rooted its action-oriented effort in four workgroups:

1. Data Intelligence & Information
   Sharing
2. Case Conferencing
3. Creative Housing & Stability
   Solutions
4. Optimizing Community-Based
   Care Coordination

Workgroups were designed to be interconnected and support the efforts of other workgroups. Their aims and structures are as follows:

Data Intelligence & Information Sharing

• Combine, visualize, track, advance, and share data with the community and within the Collaboratory to understand the population of focus.
• Build off the initial findings of the landscape analysis to link data to outcomes and measures, link data to communications, and create systems for sharing data and outcomes among players.
• Meets monthly

Creative Housing & Stability Solutions

• Identify and advance the use of creative housing solutions for older adults experiencing homelessness.
• Catalog current housing options, key partners, and funding opportunities for creative housing in the West Valley.
• Seek to optimize existing solutions in the community and identify new solutions for the market.
• Develop coordinated strategies to deliver cross-sector services to support housing stability and prevent homelessness for older adults.
• Meets monthly

Case Conferencing

• Stand up a cross-sector care coordination case conferencing structure specifically focused on older adults experiencing homelessness or housing insecurity in western San Bernardino County, including:
  • Assessing the current needs that case conferencing can address,
  • Developing a structure for the Collaboratory case conferencing efforts,
  • Mapping workflows, and
  • Testing case conferencing methods.
• Build on national best practices and existing cross-sector coordination work in the area.
• Use this older adults-focused case conferencing effort as a supplement to other case-conferencing efforts in the region.
• Meets biweekly

Optimizing Community-Based Care Coordination

• Understand community-based care and how to best coordinate efforts.
• Map out the existing providers and resources.
• Develop workflows to optimize the use of existing resources.
• Pilot new methods for coordination.
• Meets as needed

Moving forward, optimizing care coordination work will align directly with system barriers and themes that emerge from case-conferencing tables.

Each workgroup co-designed the way they work together, including their norms, cadence of meetings, goals, and workplans to build buy-in and ensure success and sustainability.

Planning for Sustainability of Relationships, Processes, Structures, and Financing of the Effort

Sustainability ensures that the efforts and successes of an initiative continue to operate effectively, adapt as needed, and produce positive outcomes for the long term. From its inception, the CCAHSAA Collaboratory has planned for sustainability by engaging key players in the community, prioritizing relationship building, seeking funding to support this work, and learning from national best practices.

The group also created a logo to represent their Collaboratory, which has inspired deepened commitment by members. The logo and associated branding will also support recognition from the community and potential funders, signifying that this work is here to stay for the long term.

For Connected Communities of Care to be sustainable, intentional efforts must be put in place to:

1. Generate buy-in, motivation, and agency from all involved.
2. Build trusting relationships between key players.
3. Cultivate local leaders to provide direction and guidance.
4. Identify and leverage financial and other assets, including local resources, organizations, advocacy, cultural networks, technology, and physical structures.
5. Utilize improvement methodologies to foster continual learning and adapting of processes.

Celebrating Successes and Harvesting Learning

Celebrating and harvesting successes—even the small ones—is an important practice in generating buy-in, maintaining momentum, and accessing assets and funding. In addition to the regular workgroup meetings, the Leadership Group convenes monthly and Collaboratory members meet in person every few months to celebrate accomplishments and plan for the future work together. This allows the group to fuel their passion for the work and capture success stories that support the longevity of these efforts.

At the second workshop meeting, Collaboratory members shared aspects of the work that brought them pride:

A key lesson learned in this approach is that the broader community is also interested in learning about cross-sector initiatives. In response, future planning will include broader community events to pull in adjacent partners with vested interests, people with lived experience, and elected officials—continuing to build a strong narrative about the power of coming together in community to solve complex problems.

Looking Ahead: From Collaboration to Lasting Change

The CCAHSAA Collaboratory demonstrates what is possible when a community moves beyond fragmented responses and commits to building a true Connected Community of Care. By bringing together housing, health care, social services, local government, and people with lived experience, western San Bernardino County is creating the relationships, infrastructure, and shared accountability needed to better serve older adults experiencing homelessness and persistent housing insecurity.

While no single organization can solve a challenge of this complexity alone, collective action can create a system that is more proactive, more humane, and more effective. As the Collaboratory continues to learn, adapt, and scale what works, it offers a powerful example for communities everywhere seeking to meet the needs of aging adults with dignity, stability, and coordinated support.

Nearly 40 organizations are represented in the Collaboratory: Access TLC; Arrowhead Regional Medical Center; Big Wins with AI; Christian Development Center; City of Rancho Cucamonga; Community Action Partnership of San Bernardino County; Correctional Health Treatment Centers; Foothill AIDS Project; Inland Empire Health Plan; Inland Housing Solutions; Inland Southern California United Way 211+; Institute on Aging; Kaiser Permanente; Kindful Restoration; Lifeway Church; LightHouse Social Service Centers; Loma Linda University Health; Manifest MedEx; Molina Healthcare; Mountain Homeless Coalition; Orchid Court; Pacific Clinics; Partners in Care Foundation; Play 2 Fitness Rolling Start; San Antonio Regional Hospital; San Bernardino County Aging and Adult Services, Behavioral Health, Community Development and Housing, Health & Human Services, Office of Homeless Services; San Bernardino Outreach Team for Homeless Support; Simple Solutions Psychotherapy; Step Up on Second; Symba Center; Veterans Affairs; Volunteers of America Southwest; and Wise & Healthy Aging Long Term Care Ombudsman Program.