When caring for the most vulnerable residents in the Inland Empire, it truly takes a village­—or a neighborhood.

“Our mission is to provide care to anyone, regardless of situation or circumstance,” said Dr. Rakesh Patel, CEO of Neighborhood Healthcare, which first partnered with Inland Empire Health Plan (IEHP) in 2018 for the Health Homes project. “We believe that health care is a right, not a privilege.”

The all-encompassing services offered by Neighborhood Healthcare – along with the organization’s commitment to serve in the IE – were among the reasons it received the IEHP 2024 Vibrant Health Award, which “honors a provider, entity or community partner that exemplifies engagement with the well-being and joyful life of Inland Empire residents.”

When Health Homes morphed into Enhanced Care Management (ECM) as part of California Advancing and Innovating Medi-Cal (CalAim), a wide range of services were made available to the people who needed them the most, according to Dr. Patel.

“ECM is critical because what it takes is those patients that are really in need, that are high-risk for either ER (emergency room) or hospitalization or high-specialty care costs and it wraps around these services to them,” he said. “It provides nursing, therapists, physicians, outreach workers that connect with that patient on a different level, so they get the services and the care that they deserve and need to avoid those other challenges in life.”

Some of those challenges can include patients on 10 different medications, dealing with the effects of multiple diseases and chronic conditions. They may also be unsheltered or facing food insecurity.

“Medical care is just a small part of what it takes to keep someone overall healthy and well,” Dr. Patel said. “We’re trying to work with them on those social determinants of health – making sure they’re linked to food, housing, transportation and our ECM team helps kind of connect those dots for those patients.”

Because of the support provided by IEHP, Neighborhood Health patients benefit from the care team that results from the ECM connection.

When a caregiver from Neighborhood Health sees a patient, they might have 15 minutes. But with ECM, more people are brought on – a whole team who has more time to understand what’s going on with a patient, Dr. Patel added.

“When the payer and the providers come together like this, we can do so much more together,” he said.