Homelessness is a major challenge for the City of San Francisco. From a medical perspective,
a small minority (13%) of the homeless population not enrolled in Medi-Cal create the majority
(71%) of the healthcare costs annually.
The City of San Francisco had launched a 4-year (2016-2020) pilot program called Whole Person Care. The vision of the initiative is to “transform San Francisco’s response to homelessness into a comprehensive, seamless and human-centric system of care in which homelessness is rare, brief and one-time, and the most vulnerable receive care that helps them lead healthier lives.” 
The City approached Fjord to help to create a holistic, human-centred process that would increase the retention of Medi-Cal amongst the homeless population.
Over the period of 8 weeks our team ran through the whole design process to present concrete opportunities to the city to improve the Medi-Cal enrollment and the related experience.
Discover
We started by interviewing the key project stakeholders to understand the current Whole Person Care initiative, its goals and previous efforts. We then interviewed Front Line Providers who are working closely with the homeless population. The Front Line Provider workers include case workers, doctors, Navigation Center workers and encampment resolution team members. We also interviewed Peer Navigators who are formerly homeless people.
After these conversations we synthesized the interviews and created a user journey for the intake process from awareness about Medi-Cal all the way to how people remain enrolled in it. In an earlier meeting with the City, we had defined two personas, Hal and Mildred. In order to emphatize with the people we were designing for, we created two different journeys for our personas.
Describe
We found out that there’s a very limited amount of resources to educate clients about Medi-Cal. It sets another challenge for the enrollment, since it is a complicated, multi-step process that often requires help from a case worker. There’s also a lot of mistrust towards authorities so the case workers need to establish trust in their clients. Verification of identity can be a challenge since the clients sometimes lack an ID. Another hurdle for the enrollment is following up: because the clients don’t have a permanent address, the enrollment paperwork often goes missing. Even after obtaining Medical-Cal, the renewal process sets new challenges since the auto-renewal option response time is short.
In this phase we planned and facilitated a full day long workshop with the City stakeholders to share and validate the research findings and to co-create ideas for the opportunities the team had discovered during research.
The team then took the ideas created during the workshop and further developed them into well-rounded concepts to cover the enrollment journey points.
Design & Deliver
The final outcome was a service blueprint that illustrates a person’s journey as they go through the Medical-Cal enrollment process. It gives the city suggestions for new types of services and products for increasing the retention of Medi-Cal among the target population. We also recommended ways to better care for the most vulnerable individuals.


Future
After the first phase of the project the City continued working with Fjord to lay out a strategy to further develop some of the ideas presented in the blueprint. Per Fjord’s suggestion, the City is for example investing in a new type of case worker who would be actively helping the homeless where they are: on the streets and at the shelters, helping them to enroll on Medi-Cal and providing other help based on the person’s situation. 

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