Serving The Poor and Vulnerable Through Community-Based Care Management

Serving The Poor and Vulnerable Through Community-Based Care Management

When a patient shows up at St Joseph Health, Queen of the Valley Medical Center with complex health conditions that suddenly become life threatening, a spiraling web of medical and psychosocial issues can complicate the immediate problem and block recovery. For some patients, the setback can seem insurmountable. Often at the root of the crisis are poverty, social isolation, housing and food insecurity, lack of caregiving resources or family support, behavioral health problems as well as lack of a medical home, medications and insurance. 

These are the patients of the CARE Network. Many CARE Network clients have multiple chronic conditions, are homeless or marginally housed or lack basic needs such food and transportation. Many also suffer from substance use disorder or mental health issues. All have inadequate or no financial resources and limited social support. Clients often use the emergency room for care, some as many as 50 times a year. They may also have language barriers and lack understanding of the healthcare system. They might miss primary care appointments and misuse medications. CARE Network addresses root causes of poor health, meeting the unique needs of those served, building self-sufficiency, improving quality of life and health outcomes and reducing overall healthcare costs and social burden on individuals, families and the community.

Program manager Aura Silva said, “Our clients need intensive services to manage their health conditions. We know that without addressing basic needs – food, shelter, economic stability, for example – managing health conditions won’t happen.”

In 2019, CARE Network added a specialized mental heath team to meet the needs of patients with mental health conditions that prevented them from addressing critical or life-threatening health issues.

CARE Network’s Mental Health Nurse met Sandra who was new to Napa County, living alone in an isolated area without family and other social supports. Her only contact was at her primary care provider at the community health clinic and they had referred her to CARE Network because she needed surgery that her unmanaged high blood pressure and mental health issues prevented. Sandra was scared, distrustful, confused, overwhelmed and unable to manage her situation. She needed psychiatric and medical stabilization and access to community services to stabilize basic needs.

With care and time, Sandra engaged with the team and her medication adherence and blood pressure improved. The surgery was successful. She now is seeing a psychiatrist who is making necessary changes to her psychiatric medication. With a lot of support from the team’s social worker, she was able to have in home help. She has been accepted for county mental case management for ongoing support. The team encourages her to find meaningful social connections and has connected her to services that will help her live independently in the community and avoid psychiatric issues and hospitalization. 

The CARE Network program is a mission-driven, evidence-based and nationally recognized model serving highly vulnerable individuals through intensive, community-based medical and psychosocial care management. Using an interdisciplinary team of registered nurses, social workers, community health workers and behavioral health specialists, the Care Network team works to improve health outcomes and quality of life for their clients. Upon intake, each client receives a comprehensive medical and psychosocial assessment conducted in the patient’s home, program office, shelter, CARE Network Program office or other safe space. Based on assessed needs, patients receive intensive, individualized one to one services (typically 3-12 months) that provide medical care coordination and assisted navigation to critical resources to address basic needs (food, shelter, medications, medical care and financial support). Case managers work directly with health care providers, community providers, County Social Services and Mental Health and Alcohol and Drug Services to address each client’s unique needs. Once high acuity needs are addressed, caregivers work to enhance self-sufficiency, and disease self-management through education and coaching and linkage to ongoing support services.

In 2019, the St. Joseph Health, Queen of the Valley’s CARE Network program served 1,108 clients with a continuum of care management services from brief care navigation to intensive services. Care Network tracks program success through indicators that show whether clients are managing their health, utilizing community health care resources and improving their quality of life. In 2019, data show 60% of clients demonstrated an overall improvement in SF12 quality of life measures. They reduced their use of the emergency room and stayed out of the hospital with an overall 71% reduction in hospitalizations and 83% reduction in emergency department use when comparing post enrollment to one year prior to enrollment.

Partnering with the hospital, primary care and community partners, the CARE Network improves systems of care to more fully meet the needs of the population. CARE Network patients are referred from hospital inpatient and emergency services, primary and specialty care physicians and community-based organizations. Interdisciplinary care management teams comprised of registered nurses, social workers, community health workers and behavioral health specialists expand access to a continuum of healthcare and other resources that improves quality of life and supports optimal health for high risk and vulnerable populations. CARE Network works closely with the County Homeless Whole Person Care Program. Partners reported, “The comprehensive care coordination provided by CARE Network was essential in supporting clients to complete treatment, access medical care (and other critical resources) as well as to accept and remain in housing.”


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