NorCal Providence reaches out into the community to identify and address the health challenges of the underserved

NorCal Providence reaches out into the community to identify and address the health challenges of the underserved

 Recently, the CARE Network team at Providence Northern California got a call from a Napa County homeless shelter. There was a 67-year-old man there who had just arrived from a skilled nursing facility, where he had spent more than two years recovering from a significant accident. He had arrived in Napa with no money, no belongings, no food, no shelter, no physical form of identification, and no knowledge of a social security number. He was not even legally identifiable.

Upon arrival, the Providence nurse and social worker found the man in desperate need of medical attention. He had unmanaged diabetes and blindness, partly due to two detached retinas. The CARE Network team worked quickly. First, they addressed his medical needs without hesitation. Meanwhile, the social worker contacted Congressman Mike Thompson’s office and began the hunt for the man’s legal identity, which was verified in less than two months. This enabled the team to get the man’s Medicaid transferred to Napa County, securing ongoing access to medical care. 

Providence also agreed to sponsor the man’s utility bills, qualifying him for Project Roomkey, a California initiative to temporarily house people in vacant hotel rooms that is partially funded by Providence. After helping him get permanently housed, the team ensured he was approved not only for caregiver services, but also for independent living and job skills training from the Earl Baum Center for the Blind.

Providence Northern California believes in community health investment, it’s an integral part of their core mission of, compassion, Justice, and dignity. In 2020, alone, Providence contributed $112 million in total benefit to their communities, including $65 million to the unpaid cost of Medicaid and other means-tested government programs, $22 million to community health improvement and strategic partnerships, and $18 million to free and discounted care for the uninsured and underinsured. But while financial backing is obviously crucial, as the Napa man’s story illustrates, there’s more to the word “investment” than just money.

“In all we have more than 120 caregivers out in the community.”

— DANA CODRON, REGIONAL DIRECTOR OF COMMUNITY HEALTH INVESTMENT FOR NORCAL PROVIDENCE

“Other hospitals primarily make cash donations,” says Dana Codron, Regional Director of Community Health Investment for NorCal Providence. “We do that too. But in addition, we have a cadre of frontline community workers across the region, from dentists to nurse practitioners to health educators, trying to strengthen that safety net and care for the most vulnerable. In all we have more than 120 caregivers out in the community.”

This is about more than just meeting patients where they are and administering care to those who might not otherwise make it into a physician’s office or hospital. Having a “frontline” presence and a firsthand perspective on the population’s needs also informs how NorCal Providence spends its money and resources in real time to ensure that money and energy is put to optimal use in fostering a healthier community.

For instance, when COVID-19 hit, NorCal Providence was uniquely positioned to quickly pivot and respond to the community’s immediate needs. They had nurses already embedded with county and state health officials to help provide outreach, PPE supplies, testing, and eventually, vaccination. During the economic fallout in the pandemic’s wake, they also had caregivers on the spot to help with food distribution and temporary housing.

Of course, COVID-19 remains a critical health issue throughout the region. But the pandemic also continues to exacerbate pre-existing challenges that have come up in NorCal Providence’s Community Health Needs Assessments—the most urgent of which are homelessness, equitable access to care, and mental health and substance use disorder. And over the past year, NorCal Providence has leveraged its “frontline” presence to promote and partner in several innovative approaches to address these problems.

Home is where the health is

One of the most persistent social determinants of health that continually presents challenges in Northern California is having a roof over one’s head. Secure housing provides more than just shelter and safety. It’s often a base from which an individual and entire families build their lives.

“We know that inadequate housing leads to poor health outcomes,” says Codron. “And we’re not just talking about the lone elderly individuals experiencing homelessness. There are entire families with children living out of their cars. And the longer they are without stable housing, the worse their health outcomes are and the shorter their lifespans.”

NorCal Providence has leveraged its resources and partnerships to help provide that stable housing—along with a means of support to help these individuals stabilize other factors of their lives.In 2020, they committed $3.5 million and partnered with Humboldt County and the state to leverage an additional $8.6 million to convert the shuttered Humboldt Inn into 42 permanent supportive housing units, plus 6 units to provide recuperative care services for people transitioning from hospitals. The project, called Eureka: Providence Mother Bernard House, will provide long-term housing for people experiencing or at risk of experiencing homelessness—particularly those at high risk for serious illness.

It is impressive that since 2018 Providence has committed $10.3 million toward housing. Similar efforts are also underway in Napa and Sonoma, where Providence is investing over $6 million in housing and permanent supportive housing initiatives.

On the road

Getting people to the doctor’s office, the hospital, and even the emergency room has always been a challenge. Many people, particularly in poorer, marginalized communities face transportation issues, work jobs that won’t allow the time off, or are homebound due to an illness or injury. So, NorCal Providence decided to bring the healthcare to them.

The Providence Mobile Health Clinic is a clinic on wheels for Sonoma County’s most vulnerable residents—especially during the increased economic woes and health challenges during the pandemic. The clinic consists of a bilingual staff of two nurse practitioners and three medical assistants who can treat minor medical conditions, help manage chronic disease, screen for other health issues, perform physicals and wellness exams, administer immunizations, provide health and nutrition education, and otherwise refer patients to other community resources.

“It’s more than a health van—it’s more like a very large RV,” says Victor Jordan, Regional Chief Executive of NorCal Providence. “It’s a rolling physician’s office. This is a pro-active investment. Those are actions we can take to help our community get and stay healthy before they would need to otherwise seek treatment in our hospitals, especially the ER.”

And during the pandemic, this “physician’s office on wheels,” was adapted to test and screen people, including those experiencing homelessness, for COVID-19.

“It’s a rolling physician’s office. This is a pro-active investment. Those are actions we can take to help our community get and stay healthy before they would need to otherwise seek treatment in our hospitals, especially the ER.”

— VICTOR JORDAN, REGIONAL CHIEF EXECUTIVE OF NORCAL PROVIDENCE

Attacking alcoholism and substance use disorder

As if we weren’t under enough stress before, COVID-19 has certainly heightened our anxiety. And for people who were already living with behavioral health issues, particularly substance use disorder, matters are even worse. Especially in Humboldt County, where the rates for drug- and alcohol-related outcomes are among the highest in the state.

“What we’re seeing in our communities is a high proportion of emergency room visits for alcohol intoxication and drug useand very few community based services,” says Codron.

Enter Waterfront Recovery Services, a new medically managed detox and residential addiction treatment center in Eureka. Of the 56 total beds, 20 will be for medically managed detox and 36 for longer term residential treatment. The facility will be operated by Alcohol and Drug Care Services with $1.6 million in grant funds from the Wellbeing Trust, founded by Providence St. Joseph.

Also in Humboldt County, NorCal Providence teamed with the county health department, North Coast Health Improvement and Information Network, and the California Center for Rural Policy at Humboldt State University to create the Humboldt RISE Project. The program encourages understanding and de-stigmatization of perinatal substance use disorder among pregnant women, who, in Humboldt, experience the disorder at a rate three times the state average.

A great tradition of reaching out

NorCal Providence also realizes that every individual has unique, complex, and often overlapping social and medical needs. That’s why they’ve doubled down on an integrated care model that is exemplified by the CARE Network program.

CARE Network teams use an interdisciplinary approach of registered nurses, social workers, community health workers, and behavioral health specialists to help those at-risk populations with inadequate or no financial resources and limited social support. Partnering with the hospital, primary care providers, and community partners, the CARE Network takes clients referred from inpatient and emergency services, as well as primary care physicians and community-based organizations, and provides medical care coordination and assistance to finding food, shelter, and other basic needs.

It’s just one more example of Providence getting out and investing their time, as well as their money in the health of the larger community. “When you look at the work the Sisters of St. Joseph did, and the Sisters of Providence, it was all about reaching out into the communities,” says Jordan. “That was their mission and that’s what they did. That is our tradition. We reach out into the community, identify the needs, and then help where we can.”