501(c)(3) Nonprofit · Los Angeles County

Elder Healthcare Navigation & Stabilization Pilot

Connecting vulnerable seniors to the care they need — reducing ER overuse, avoidable hospitalizations, and failed specialist coordination across Los Angeles County.

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3×
Dual-eligible seniors use the ER 3× more than privately insured patients
68%
Of low-income seniors miss specialist follow-up within 30 days of discharge
$8K+
Average cost per avoidable hospital readmission to health systems
The problem we solve

Why vulnerable seniors fall through the cracks

"Low-income and housing-insecure older adults frequently fail to access medically necessary specialty care because they cannot independently navigate healthcare systems, transportation, referrals, paperwork, or digital systems."

— Senior VP, BHBF
Repeat ER use Many seniors return to the emergency room when specialist follow-up, transportation, or medication support never connects after the first visit.
Readmission risk Hospital discharge plans often break down without a navigator to schedule appointments, confirm instructions, and check in after the patient goes home.
Unmanaged chronic care Conditions such as diabetes, hypertension, and heart disease worsen when routine visits and prescription refills are not coordinated over time.
Social isolation Without a trusted advocate, older adults may skip appointments, delay treatment, or disengage from care plans entirely.
What we provide

Navigation & coordination services

Ben Harris Business Fund does not provide medical treatment. We provide the connections, coordination, and hands-on support that make treatment possible and effective for medically vulnerable elders.

We carefully vet all vendors and partners for quality, professionalism, responsiveness, and cultural competency — so seniors receive reliable support they can trust.

Healthcare navigation

  • Scheduling specialist appointments
  • Referral tracking and coordination
  • Discharge instruction support
  • Care team communication

Transportation coordination

  • Arranging medical rides
  • Accompanying elders to appointments
  • Same-day and scheduled transport
  • NEMT coordination support

Medication & follow-up

  • Pharmacy coordination
  • Appointment reminders
  • Post-discharge follow-up calls
  • Compliance tracking and support

Benefits navigation

  • Medi-Cal & Medicare enrollment
  • SSI and IHSS applications
  • CalAIM Community Supports
  • Housing resource referrals

Digital assistance

  • Patient portal setup & navigation
  • Online scheduling support
  • Telehealth assistance
  • Digital literacy coaching

Community engagement

  • Interactive health workshops
  • Benefits literacy trainings
  • Multilingual sessions
  • Trusted community settings
Target population

Who we serve in Los Angeles County

We specialize in reaching seniors most likely to fall through the gaps of the healthcare system — and most likely to become high-cost, high-utilization patients without intervention.

Medi-Cal eligible seniors Adults 65+ enrolled in Medi-Cal or county-managed care plans who need help finding providers, understanding benefits, and completing enrollment or renewal paperwork before coverage lapses.
Dual-eligible individuals Seniors who qualify for both Medicare and Medi-Cal — often facing conflicting rules, duplicate bills, and confusion about which plan pays for what. We coordinate across both systems so nothing falls through the cracks.
Socially isolated elders Older adults living alone or with few family caregivers who miss appointments, forget medications, or lack anyone to advocate for them during hospital stays and specialist visits.
Housing-insecure older adults Seniors in shelters, transitional housing, or unstable living situations who struggle to maintain a mailing address, store medications safely, or access consistent primary and specialty care.
High ER utilizers Patients with repeated emergency visits — often because underlying conditions, follow-up appointments, or prescriptions were never coordinated after the last discharge.
Cognitively overwhelmed patients Elders with memory loss, limited English proficiency, or low health literacy who cannot manage patient portals, insurance forms, referral slips, or multi-step care plans on their own.
Measurable impact

Stronger outcomes for seniors and health systems

Our navigation model is built to improve access, continuity of care, and performance on the metrics partners track every day.

↓ Emergency department use
We help members reach primary and specialty care before a manageable concern becomes a repeat ER visit.
↓ Hospital readmissions
Structured post-discharge follow-up keeps appointments, medications, and care instructions on track at home.
↑ HEDIS performance
Consistent outreach supports follow-up visits, medication adherence, and other quality measures plans are rated on.
✔ CalAIM alignment
Our services align with Health-Related Social Needs requirements for Enhanced Care Management and Community Supports.
Why health systems choose us

A trusted community-based care navigation partner

Ben Harris Business Fund is positioned as a healthcare access stabilization and care coordination organization — not an informal advocacy group. We speak the language of value-based care, HEDIS metrics, and CalAIM compliance.

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Reduce avoidable costs Proactive navigation reduces avoidable ER visits, readmissions, and complications from unmanaged chronic conditions that increase system-wide costs.
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Move HEDIS numbers Our follow-up calls and medication coordination directly support the HEDIS and quality measures health plans are accountable for each year.
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CalAIM alignment We deliver Health-Related Social Needs services that align with Enhanced Care Management and Community Supports contracting requirements under CalAIM.
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Community trust We meet members where they are — through trusted community settings, multilingual outreach, and relationships built over time.
Ideal partners
Kaiser Permanente
L.A. Care Health Plan
Health Net
LA County DHS
Hospital Systems
ECM Organizations
Get involved

Partner with us to strengthen senior care in Los Angeles County

We welcome collaborations with health plans, hospital systems, and CalAIM organizations that want community-rooted navigation, measurable quality gains, and dependable support for older adults navigating complex care.

Schedule a partnership meeting Email us directly
Contact us
Phone 1-323-855-2415
Website 019angels.org
Email [email protected]
Service area Los Angeles County, California