CARE Network

The CARE Network at St. Joseph and Redwood Memorial Hospitals assists people during times of transition between hospital and home. The program offers individual health care navigation and interventions to select populations of patients with an overall goal of providing individuals tools needed to become active partners in their health management, especially during times of transition between health care settings. Medication self-management, disease process education, Behavioral Health Services, support for follow-up visits and respite housing are some of the interventions provided.

The CARE Network team coordinates planning of services with inpatient discharge planning as well as the emergency department, then works with patients outside of the hospital setting. The care and services provided by the team are person-centered and focused on a community-based, multi-disciplinary approach, linking individuals to the various resources available to help meet ongoing health care needs.

The CARE Network team consists of registered nurses, social workers and health care navigators.

Services are voluntary and provided free of charge to patients.

Clients Who May Benefit from a Referral to CARE Network

  • Those with a new diagnosis impacting health care needs
  • Clients with chronic disease
  • Those with multiple medications, new medications and/or changes to existing medication regimen
  • Clients with a recent hospitalization or multiple re-admissions
  • Those with multiple clinical specialists or who are without a Primary Care Provider
  • Persons with a substance use issue

CARE Network Services

Chronic disease management

  • Community Visits: patients with complex chronic illnesses resulting in poor disease management, multiple hospital or emergency room visits and/or inpatient readmissions.
  • Referrals: Christine Williams, ACSW 707-445-8121 ext. 5845

Primary care social work

A social worker supports Primary Care offices at St Joseph Health Medical Group and assists patients with health care navigation, mental health services, medication assistance, long term care planning and financial assistance.

Substance use disorder (SUD) services and navigation

Emergency Department Substance Use Navigator (SUN) aka ED Bridge Navigator

  • Population Served: emergency department patients with substance use issues who would benefit from and are interested in substance use treatment. Linkage to Medication Assisted Treatment (MAT) provided.
  • Referrals: Yvette Cerna 707-445-8121 ext. 5840

Complex case management

  • Population Served: patients needing Medical Respite (see below) and/or patients at high risk for readmission to the hospital or multiple emergency department visits due to complex social and medical issues.
  • Referrals: Christine Williams, ACSW 707-445-8121 ext. 5845

Medical respite program

The Medical Respite program is for homeless individuals who are being discharged from the hospital, and who need the opportunity to rest in a safe, healing environment while accessing medical care and other supportive services post-hospitalization. The CARE Network Team provides care coordination, case management and transitional assistance to respite clients throughout their stay.

The CARE Network’s Medical Respite program has been nationally recognized, with featured link below:

American Hospitals Association’s “Social Determinants of Health” series’ Housing and the Role of Hospitals playbook: hpoe.org/resources/ahahret-guides/3063

Services are voluntary and provided free of charge to patients.

For more information about CARE Network, contact:

Joy Victorine, MSW
Area Manager, Transitional Care and Community Programs
Send an email
707-445-8121 ext. 5825