The CARE network in Northern California
A CARE Network social worker speaks with a client at one of the respite homes in Eureka, CA.
Imagine you just had surgery or intensive treatment for a chronic illness. You are leaving the hospital, tired and weak, and need a safe environment to recover. Now imagine you have no place to go. No home or shelter of any kind.
This was the situation James faced in 2010. At the time, James was 55 years old with Type 1 diabetes and alcohol dependency. After being assaulted, James received care for a collapsed lung at St. Joseph Hospital’s emergency department in Eureka, California. When James was ready for discharge, he did not have an adequate place to recover. Fortunately, through the combination of dedicated caregivers and community benefit programming, James had a safe place to heal.
For nearly 20 years in Napa County, California, St. Joseph Health has funded and operated the CARE Network–Care management, Advocacy, Resource referral and Education Network – for people who are low-income and chronically ill, including those experiencing homelessness. Using a continuum of care model, the CARE Network provides a range of care management services. This program helps the most vulnerable patients to access temporary respite shelter, and then works to help them manage chronic conditions and transition into better living situations. In 2018 alone, SJH invested more than $3.7 million into its CARE Network.
The successful model in Napa County has recently been replicated in both Humboldt and Sonoma counties. By providing the full scope of services from temporary housing to behavioral health care and medication compliance support, CARE Network caregivers and partner organizations help individuals get the care they need. As happened in James’ situation, social workers, nurses and community health workers often arrange follow-up visits with their patients, build trust and make connections to critical community resources.
The impact has been remarkable.
In 2018, the Humboldt County CARE Network saw 70 percent of those served complete their respite stay and follow-up medical care. Of those, nearly 80 percent transitioned into stable housing.
Not only are patients healthier and safer when they can fully recuperate and receive follow-up medical care, they are also less likely to immediately return to the emergency department. This reduces overall health care costs that are often borne by communities and helps ensure patients get care in the most appropriate setting. In Sonoma, the hospital readmission rate for individuals served by the CARE Network is less than half the standard hospital readmission rate of 12 percent.
The program’s success as a community catalyst has not gone unrecognized. Queen of the Valley Medical Center – home of the CARE Network – received the Foster G. McGaw Prize for Excellence in Community Service in 2014.
For Dana Codron, St. Joseph Health Northern California’s longtime Regional Director for Community Health, stories like James’ are reminders that serving those in need lies at the heart of SJH’s mission. “We have a deep history in our communities of helping the vulnerable, those who are low income and who have chronic illness,” said Codron. “It’s important to meet people where they are, ask them what their needs and goals are, and in doing so, we gain their trust to further assist them with other needs.”