For Community

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 coaching 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, personal health record keeping, disease process education, 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 healthcare needs.

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

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
  • Clients with multiple Emergency Department visits
  • Those with multiple clinical specialists or who are without a Primary Care Provider

Medical Respite Program

In addition to the above services, the CARE Network has partnered with local organizations to provide Medical Respite.

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.

Locations:

  • Betty’s House: 10 Beds with onsite staff support and meals provided by the Betty Kwan Chin Homeless Foundation
  • Dale Ward Clean & Sober Housing: 5 beds; peer to peer support
  • Serenity Inn: 1 room which may accommodate a couple with or without children

National Recognition

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

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

Watch the story behind St. Joseph Health’s, Humboldt County, Medical Respite Program narrated by Joy Victorine, Manager, Care Transitions: http://link.videoplatform.limelight.com/media/?mediaId=1d804cc2d6ca42aa91349296cde89ecc&width=1024&height=576&playerForm=Player

Healthcare Dive, “Hospital’s tackling homelessness to bring down costs”, 2018:
https://www.healthcaredive.com/news/hospitals-tackling-homelessness-to-bring-down-costs/510631/

Program Process:

  • Hospital staff and/or discharge coordinators identify clients who may benefit from interventions provided by the CARE Network team
  • A referral is made to the CTP team
  • Post-discharge, clients receive a follow-up phone call and/or community-based visit from the CTP team
  • RN can help with medication reconciliation, disease process review and education and support in follow-up visits with a clinician/specialist
  • Social Worker and Health Coach focus in solutions for issues related to social determinants of health, such as lack of financial resources, limited access to primary care, barriers to transportation and other necessary community resource needs
  • Additional visits are scheduled as needed

For more information please contact:

Joy Victorine, MSW
Area Manager, Transitional Care and Community Programs
joy.victorine@stjoe.org
707-445-8121 ext 5825

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