01
Healthy Living
"Atlas connected me with a nutritionist and a six-month plan. I lost 40 pounds in three months and got my motivation back."
— Mike, 46
DHCS CalAIM · California
01 —Populations of Focus
Whole-person care for California's highest-need members.
Atlas brings the full CalAIM toolkit — Enhanced Care Management (ECM), Community Supports (CS), Behavioral Health (BH), Community Health, doulas, and MAT — directly to the members who need it most: people reentering after incarceration, unhoused Californians living with SMI/SUD, and families navigating high-risk pregnancy.
- 3
- CalAIM Populations of Focus
- 90d
- Pre-release reentry in-reach window
- 12mo
- Postpartum coverage & follow-up
- 24/7
- Street Medicine on-call access
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Populations of Focus
Three populations.
One CalAIM promise.
Atlas concentrates DHCS CalAIM investment where the return is measured in lives — the three CalAIM Populations of Focus most affected by fragmented care.
- 01
Justice-Involved Reentry
Ninety days can decide the next ten years.
Warm-handoff care for adults and youth returning to the community from jail, prison, or juvenile facilities.
- 02
Homeless with SMI / SUD
The clinic comes to the curb.
Street-based, harm-reduction care for unsheltered members living with serious mental illness or substance use disorder.
- 03
Birth Equity (High-Risk Pregnancy)
Black mothers are 3–4× more likely to die from pregnancy in California. We are here to change that math.
Doula-supported, culturally-matched care for pregnant and postpartum members at elevated risk of maternal morbidity.
03 —
Our Approach
With you every step of the way.
Wellness is a journey, not a destination. Every path is unique—and so is the care we provide.
- 01
We listen first
A Lead Care Manager learns your story, your goals, and the obstacles in your way.
- 02
We build a plan together
Medical, behavioral, and social supports coordinated under one roof—no more juggling.
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We walk beside you
From doctor's visits to housing applications, we show up so you don't have to do it alone.
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Why these three
The populations California cannot afford to lose.
CalAIM concentrates Medi-Cal's most powerful tools where fragmented care creates the sharpest human cost. Atlas puts those tools to work.
- 40K+
- Californians released from state prison each year
- 187K
- Californians homeless on any given night — 68% unsheltered
- 3–4×
- Higher maternal mortality for Black birthing people in CA
The 90 days before the gate opens are our highest-leverage window — a warm handoff can cut 30-day recidivism and slash the post-release overdose spike.
Source · CDCR Offender Data Points
Street Medicine, low-barrier MAT, and Community Supports housing bring the clinic to the curb for members living with SMI and SUD.
Source · HUD 2024 AHAR Point-in-Time Count
Doula support, perinatal ECM, and postpartum home-visiting from pregnancy through 12 months are how we change the math for high-risk pregnancy.
Source · California Pregnancy-Associated Mortality Review
01
Mr. Sherman · Enhanced Care Management
Finding a new doctor in days, not months
After switching insurance plans, Mr. Sherman struggled for weeks to find a new primary care doctor. His Lead Care Manager identified an in-network physician within hours and scheduled an appointment that same week.
Same-week appointment
02
Jenny · Community Supports
Stable housing in a financial crisis
Facing eviction as a single mom, Jenny worked with our Community Supports team to secure affordable housing and a covered deposit. She avoided homelessness and rebuilt stability for her family.
Eviction prevented
03
Anonymous · Street Medicine
From the street to stable housing
A member living unsheltered was first contacted by our Street Medicine team during outreach. Over four months, they received wound care, behavioral health support, and a successful pathway into permanent supportive housing.
Housed in 120 days
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Member Stories
Whole-person care, told by the people who lived it.
02
Behavioral Health
"After my divorce I felt adrift. Through compassionate behavioral health, I found clarity, resilience, and new dreams."
— Mark
03
Community Supports
"When eviction was days away, Atlas guided me to affordable housing and covered the down payment. My kids have a home."
— Jenny
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In partnership with California's leading health plans
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Get started
For partners
Refer a member in under 5 minutes.
Jails, hospitals, FQHCs, health plans, OB practices, shelters, probation, drug courts — send us the warm handoff and we take it from there.
For members & families
Enroll yourself or a loved one.
Medi-Cal members and their families can self-refer. No ID, no phone, no address required — we'll help build all of it.