Empowering At-Risk Community Members to Navigate Chronic Conditions

May 7, 2021

What happens when a health care system serves the whole person—mentally, physically and socio-economically?

This is precisely what the CARE Network Program has demonstrated over the past 30 years at Providence Queen of the Valley Medical Center in Napa. This mission-driven program provides intensive medical and psychosocial care management for uninsured or underinsured low-income patients. Patients receive a continuum of care that extends beyond hospital discharge into daily community life.   

CARE Network works directly with patients to increase self-sufficiency, quality of life and health outcomes, while decreasing health care costs. Many of the patients served have mental health challenges, substance use disorder or are unstably housed. CARE treats the whole patient, ensuring first that basic needs are met before building personalized treatment plans that target complex health, behavioral and social circumstances.  

This evidence-based model stands for Care Management, Advocacy, Resource and Referral, and Education, and is comprised of interdisciplinary care management teams of registered nurses, social workers, community health workers (CHWs), and behavioral health specialists.

Trust is at the forefront of this effort, and cultural and language needs are prioritized as teams establish connection with clients. Across roughly 3-12 months, clients receive intensive, one-to-one services and critical resources, personalized to fit individual circumstances.  

A recent recipient of CARE Network support is a 45-year-old uninsured man who was hospitalized with diabetes, diabetic neuropathy, hypertension, cirrhosis of the liver, and impaired vision. After assessing his case, nurses and social workers found that his bleak medical problems were increased by confusion around details of his prescribed medications.

He also faced a complicated marital relationship and dwindling money due to lack of work from ongoing illness, all while caring for his four young daughters and home. His health rapidly declined amidst a battle with his landlord over mold in his home, further pulling his family apart.

The CARE Network team of nurses and social workers tended to this case by reviewing the social, physical and economic challenges that were present, healing the root of present issues rather than placing a bandage over a multifaceted challenge. 

The social worker connected this client with Fair Housing Napa Valley and Child Protective Services of Napa County to facilitate alternative housing for the family.

“Normally there is about a two to three-year wait, but CPS Napa, under its Family Preservation Program, expedited the process and got permanent housing for the family in about two months,” noted the social worker. “With the assistance of the local family shelter, Catholic Charities and other community partners, we were able to fully furnish the home. This was the first time they had a dining room table where they could all sit down and have dinner together.”

CARE Network embodies our Mission to be “steadfast in serving all, especially those who are poor and vulnerable.”

One CARE team member reflects: “The health care system is confusing, especially for those who are poor and marginalized. CARE Network is a bridge to healthcare for those who are overwhelmed and confused by our challenging healthcare system. We provide continuity of care when people leave the hospital and don’t know how to follow discharge plans. We care for the whole person.”

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