About 1.6 million Californians face interconnected challenges that make it extraordinarily difficult to access health care and find the support they need within our complex web of health care and social services systems. They confront daunting hurdles whether they are experiencing homelessness or housing insecurity; struggling with serious mental illness; managing chronic conditions; or living with substance use disorder or cognitive decline.
To learn more about their perspectives, CHCF partnered with EVITARUS, a noted Los Angeles firm that conducts opinion research and public policy analysis. The firm’s extensive research included in-depth interviews with 99 individuals and eight focus groups of caregivers across California. The key takeaway? Trusted relationships improve care.
Recently, I interviewed Shakari Byerly, PhD, MPP, who led the research team and has a deep understanding of how social needs affect health outcomes. Her findings and observations reveal not only what assistance people need but the importance of delivering services with dignity, cultural understanding, and genuine care. Our conversation was edited for length and clarity.
Q: Your research uncovered several major themes about what Californians with multiple health and social needs value most when they receive care. The first one is trusted relationships with providers — a fundamental element that many people struggle to find.
A: We were really struck by how much the personal relationship matters, even when providers can’t meet every need. That relationship goes a long way toward making people feel listened to and treated with empathy. We thought of it as emphasizing the “care” in health care. In many situations, people said they didn’t feel that the caring nature of treatment was present. Some of this stems from system overload. Patients can see there isn’t enough housing or treatment program capacity available. The constant turnover in care managers was particularly frustrating. But when services were delivered with empathy, participants told us it made a tremendous difference by helping them feel seen and heard.
Q: Many participants talked about their goals and sense of agency during these discussions. How did that fit into the picture?
A: It starts with asking the person about what’s important to them. That can often get lost when we’re just trying to move people through services. People wanted to feel like they had some self-determination and to partner with their providers. Many said providers typically do not ask about the goals they might have for their own health or what being healthy and well would look like in their lives. Another common concern was that, given the complexity of the challenges they may be facing, providers often don’t recognize that they may not be able to follow through with aspects of the recommended treatment plan. Patients responded positively when they felt seen not as a case number but as a human being trying to be healthy and move toward stability.
Q: You mentioned cultural resonance as being particularly important. How does that differ from what we typically think of as cultural competency?
A: We’ve moved away from just checking boxes about cultural competency. Cultural resonance is about providers truly understanding nuances like language, family dynamics, or healing traditions. People need care that speaks to their lived experiences. Many participants talked about needing to experience fair treatment and the elimination of racism in care settings. That’s not only about individual provider behavior — it’s also about systemic change.
Q: You also found that people’s basic needs come before their health care. What surprised you most about how people with multiple health and social issues prioritize their needs?
A: Housing came up again and again — 61 out of 99 participants emphasized it as foundational. It has a direct impact on health. People without stable housing spend time every day meeting basic needs, such as keeping warm, obtaining food, taking a shower. That takes so much time that they neglect longer term concerns like health. But housing needs vary widely. People recovering from substance use disorder told us they’re often placed with others who are still using drugs or alcohol, and that jeopardizes their progress. Women with trauma histories sometimes find themselves in shelter situations that re-traumatize them.
Employment support came up too. Many people want to work and need that economic bridge before they can fully engage with health care.
Q: How did health care services show up in these conversations?
A: People are frustrated that they often have to reach crisis levels before qualifying for help, particularly in the behavioral health system. That’s a system failure.
Participants want robust preventive services with flexible eligibility requirements. They may not be dealing with a serious mental illness but may need counseling and therapy. They want help maintaining their own stability, not just crisis intervention.
Dental needs connected to maintaining health were a recurring theme. Some participants, particularly seniors, talked about long wait times and how the default treatment under Medi-Cal was extracting teeth rather than repairing them. Living with missing teeth makes it harder for people to eat healthy food or to find a job.
What really came through was how interconnected everything is. Someone might have critical health care needs, but if they don’t have housing, healing becomes nearly impossible. They want to eat healthy foods, but they can’t do that until they can get their teeth fixed. The system often treats these as separate issues, but people experience them all at once.
Q: You identified integrated care and “one-stop shopping” as a key theme. What do you mean?
A: The people we interviewed were recruited by community-based organizations, which are trusted by their clients to provide an array of crucial social services. Participants told us if they could get a fuller range of services that include health care, counseling, and other supports at these familiar locations, it would transform their experience. The power of services coming to people rather than the other way around is especially crucial for seniors with mobility challenges and people in underserved rural areas. It also matters for people experiencing homelessness. Street medicine providers showed us the value of care navigators and street team members building relationships over time with people experiencing homelessness.
Q: Navigating the system seems like it should be straightforward, but clearly it isn’t. What feedback did you get about the tremendous importance of care navigators?
A: One quote really captures it: “If I don’t know what’s available, how do I know what to ask for?” People are told, “You just have to ask,” but they don’t even know what exists. Many people, especially seniors, struggle with resources that are only delivered online and want to walk into an office and talk to a person, even if there’s a wait. When you submit an online form, you don’t know where it goes or who sees it. There’s no way to follow up. And when information is translated into other languages, it can still be confusing or use terms people don’t understand.
Q: What do caregivers have to say about all this?
A: The emotional toll on caregivers — both family members and paid providers — is profound. Family caregivers need financial support because many are sacrificing their own income and health to provide care. They need training, mental health support, and respite care.
Q: What would meaningful change look like for the people you talked to?
A: It starts with hiring staff who have cultural and experiential backgrounds in common with the people they are helping. Those go a long way toward building trust and improving outcomes. We also need to address the high turnover rate in care management that forces people to start over with new providers by retelling their story and rebuilding trust.
We need trusted community organizations to provide more comprehensive services, either on their own, or by partnering with other organizations. More housing that is appropriate to people’s specific needs. And we need care managers who won’t assume people can figure it out themselves and will provide help navigating available services.
The system needs multiple entry points — not just digital platforms — with clear, accessible information about available services. And throughout all of this, we must center the human relationship. People want partners in their journey toward health, not just service providers checking tasks off a list.
Q: What does your research tell us about the future of health care in California?
A: These findings validate CalAIM’s efforts to achieve whole person care that recognizes how health, housing, and social needs interact. These new programs must honor what people told us they need: care delivered with empathy, cultural understanding, and respect for their agency. In addition to coordinated services, they need trusted relationships. Most importantly, we need to remember that behind every complex need is a human being trying their best to stay healthy and stable. If we can keep that humanity at the center of our reforms, we’ll build a system that truly serves all Californians.
Authors & Contributors
Melora Simon
Associate Director, People-Centered Care
Harrison Hill
Photographer and Filmmaker
Harrison Hill is a documentary photographer and filmmaker based in Los Angeles, California. His work focuses on social justice issues centered around communities of color in the US.