How Integrated Care Works

A Visual Journey Through Our Three-Pathway Model

Understanding how medical care, behavioral health, and housing support connect to create sustainable wellness — step by step, with calm clarity.

The Circle of Care

At Second Chance, healthcare isn’t just about treating illness — it’s about addressing the whole person and the circumstances that affect their health.

Housing & Stability

Safe shelter, case management, and pathways to permanent housing

Behavioral & Mental Health

Therapy, medication management, and trauma-informed support

Primary & Preventive Care

Medical treatment, chronic disease management, and wellness educatio

These pathways work together, not separately

Why Integration Matters

Traditional Fragmented Care
  • Patients navigate multiple disconnected systems
  • Medical records don’t communicate across providers
  • Mental health and housing crises interrupt medical care
  • High emergency room use and hospital readmissions
  • Patients fall through the cracks between services
Second Chance Integrated Model
  • One team coordinates all services under one roof
  • Shared electronic health records across all pathways
  • Housing stability supports medical recovery
  • 85% reduction in ER visits among active patients
  • Continuous care coordination prevents gaps

A Patient’s Journey

Follow Maria’s story to see how integrated care creates lasting change — from crisis to stability.

1

First Contact: Emergency Room Visit

Crisis Intervention & Initial Assessment

Maria’s Situation

Maria, 34, arrives at the emergency room with chest pain and anxiety. She’s been sleeping in her car for three weeks after losing her job and apartment.

She has untreated diabetes, depression, and no health insurance. The ER treats her immediate symptoms but has nowhere to discharge her safely.

Traditional Outcome:

Discharged back to her car with prescriptions she can’t afford, no follow-up care, and instructions to “see a doctor” — which she has no way to access.

Second Chance Intervention
Hospital Liaison Connects

Our hospital liaison meets Maria in the ER, explains integrated services, and schedules same-day intake at our clinic.

Comprehensive Assessment

Maria meets with a care coordinator who evaluates medical, behavioral health, and housing needs — all in one appointment.

Immediate Stabilization

She receives low-cost diabetes medication, a referral to our therapist, and emergency housing placement that night.

2

Housing Pathway Activated

Safe Shelter & Case Management Begin

Transitional Housing

Maria moves into our transitional housing facility with private room, meals, and 24/7 support staff.

Dedicated Case Manager

Assigned case manager helps with benefits enrollment, job search, and permanent housing applications.

Weekly Check-Ins

Regular meetings to track progress, address barriers, and adjust support as needs change.

What Housing Stability Enables:
Safe place to store medications and attend appointments
Address for job applications and benefit enrollment
Reduced stress allows mental health treatment to work
Community connection and peer support
3

Behavioral Health Support

Trauma-Informed Therapy & Medication Management

Mental Health Treatment
Weekly Therapy Sessions

Maria meets with licensed therapist Annette Kee, LCSW, to address depression, anxiety, and trauma from homelessness.

Medication Management

Psychiatrist prescribes and monitors antidepressant, with adjustments based on response and side effects.

Group Support

Joins peer support group for women overcoming homelessness, led by trained facilitator.

Why Behavioral Health Integration Works

Because Maria’s therapist has access to her medical records, they can:

  • Coordinate with her primary care doctor on diabetes management
  • Address how depression affects medication adherence
  • Communicate with housing case manager about stress triggers
  • Adjust treatment based on housing stability progress
Maria’s Progress:

After 8 weeks of therapy and medication, Maria reports improved mood, better sleep, and increased confidence in job interviews.

4

Primary & Preventive Care

Ongoing Medical Management & Wellness

Regular Check-Ups

Maria sees Dr. Chen monthly for diabetes monitoring, blood pressure checks, and medication adjustments.

Continuity: Same doctor every visit who knows her full story
Lab Services Onsite

Blood work for diabetes management done at clinic, results reviewed same day, no external appointments needed.

Convenience: No transportation barriers or missed tests
Pharmacy Access

Low-cost medications dispensed onsite, with pharmacist counseling on proper use.

Adherence: No cost barriers to filling prescriptions
How Medical, Behavioral, and Housing Teams Collaborate:
Weekly Care Team Meetings

Dr. Chen (medical), Annette Kee (therapist), and Maria Rodriguez (case manager) meet to discuss Maria’s progress:

  • Dr. Chen notes improved blood sugar control
  • Annette reports Maria is more engaged in therapy
  • Maria R. shares that housing stability has reduced stress
  • Team adjusts care plan to support job search readiness
Shared Electronic Health Record

All providers see the same information in real-time:

Medical History
Current Medications
Therapy Progress Notes
Housing Status Updates
Care Plan Goals
5

Transition to Permanent Housing

Sustainable Independence & Ongoing Support

Maria’s Achievements After 6 Months
Permanent Housing Secured

Moves into subsidized apartment through Housing Choice Voucher program, with case manager support during transition.

Employment Obtained

Hired as retail associate with health insurance benefits, working with vocational counselor on career advancement.

Health Stabilized

Diabetes under control with A1C reduced from 9.5% to 6.8%, depression symptoms significantly improved.

Insurance Enrolled

Successfully enrolled in Nevada Medicaid, ensuring continued access to medical and behavioral health care.

Ongoing Care Coordination

Even after moving to permanent housing, Maria continues receiving integrated care:

Monthly Medical Visits

Ongoing diabetes management with Dr. Chen

Bi-Weekly Therapy

Continued support from Annette Kee for stress management

Case Manager Check-Ins

Monthly calls to ensure housing stability and address any issues

Peer Support Group

Continues attending to support others and maintain community

Maria’s Reflectio

“Second Chance didn’t just give me a place to sleep — they gave me a team that believed in me. My doctor, therapist, and case manager all talked to each other, so I didn’t have to explain my story over and over. They saw me as a whole person, not just a diagnosis.”

Sustainable Wellness Achieved

Maria’s story demonstrates how integrated care addresses root causes — not just symptoms — creating lasting change through coordinated medical, behavioral, and housing support.

Visual Model: How Services Connect

A simple diagram showing the continuous flow of care across all three pathways.

Intake & Assessment

Comprehensive evaluation of all needs

Housing Stabilization

Safe shelter enables treatment adherence

Medical + Behavioral Care

Coordinated treatment of body and mind

Progress Monitoring

Team adjusts care based on outcomes

Permanent Stability

Transition to independence with support

Continuous Loop

Care doesn’t end at discharge — patients can re-enter services at any point if needs arise.

Team Communication

Weekly care team meetings ensure all providers are aligned on treatment goals and progress.

Shared Records

One electronic health record accessible to all authorized providers, eliminating information gaps.

Evidence-Based Outcomes

Research and our own data show that integrated care delivers measurable improvements in health and stability.

85%

Reduction in ER Visits

Among patients receiving integrated care for 6+ months

92%

Housing Retention

Patients remain stably housed 12 months after placement

78%

Medication Adherence

Improved compliance with chronic disease treatment

98%

Patient Satisfaction

Would recommend Second Chance to others

National Research Supports Integration

SAMHSA-HRSA Center for Integrated Health Solutions

Studies show integrated care reduces healthcare costs by 20-30% while improving outcomes for patients with complex needs.

Journal of the American Medical Association (JAMA)

Integrated behavioral health in primary care settings leads to better chronic disease management and reduced hospitalizations.

Housing First Research

Providing stable housing before addressing other issues results in 85% housing retention and significant improvements in health outcomes.

Cost Savings for Healthcare System

By preventing emergency room visits and hospitalizations, integrated care saves healthcare systems an average of:

$8,500

Per patient annually in avoided ER costs

$12,000

Per patient annually in avoided inpatient care

Return on Investment

For every $1 invested in integrated care, healthcare systems save an average of $3 in reduced emergency and inpatient costs — while dramatically improving quality of life for patients.

SCCH Mobile Health van and diverse care team providing integrated primary, behavioral, and social care at a community event

Ready to Experience Integrated Care?

Explore our three service pathways or schedule your first appointment today.

Explore Our Programs

Second Chance Community Health offers integrated, sliding-scale care across Las Vegas. Nevada Medicaid accepted.