Community-Wide Safety Net Improves Care Transitions

Coordinating Community Services

Coordinating Community Services

Coordinating Community Services

The CARE Network (Case Management, Advocacy, Resource/Referral, Education) at Queen of the Valley Medical Center in Napa, Calif. provides an interdisciplinary continuum of care from hospital to home followed by community-based chronic disease management support.
The CARE Network (Case Management, Advocacy, Resource/Referral, Education) at Queen of the Valley Medical Center in Napa, Calif. provides an interdisciplinary continuum of care from hospital to home followed by community-based chronic disease management support.

Coordinating Community Services

The CARE Network (Case Management, Advocacy, Resource/Referral, Education) at Queen of the Valley Medical Center in Napa, Calif. provides an interdisciplinary continuum of care from hospital to home followed by community-based chronic disease management support.

Title:
Coordinating Social and Health Services Improves Care Transition Process

Results:
CARE Network patients have a 21 percent lower 30-day readmission rate than QVMC’s overall patients—8.3 percent versus 10.5 percent.

Institution:
Queen of the Valley Medical Center (QVMC)
1000 Trancas Street
Napa, CA 94558

Profile:
Queen of the Valley is a Catholic non-profit, full-service diagnostic and therapeutic medical facility.

Contact:
Dana Codron, RN
Executive Director of Community Benefit
Queen of the Valley Medical Center
707-251-2013
Dana.codron@stjoe.org

Innovation Implementation:

Many patients who are discharged from the hospital face obstacles to maintaining their health. For some patients, these challenges are health care related—not understanding their medication regimen or the recommended diet. For others, the obstacles may be societal—transportation and financial issues, or substandard living conditions. But for the most vulnerable of patients, it’s a combination of the two.

In Napa, California, Queen of the Valley Medical Center uses the CARE Network (Case Management, Advocacy, Resource/Referral, Education) to ensure that its patient population’s health care and economic and social needs are met and establish a seamless continuum of care from hospital discharge back into the community setting.

First and foremost, a team made up of a social worker and nurse visits the patient’s house to make sure that her most basic needs are met—the essence of the CARE Network. Often this includes arranging adequate housing and food, and arranging transportation to the patient’s follow-up primary care provider and pharmacist for the necessary medications. In many cases, the social worker is tasked with arranging needed social services like California’s Medicaid and welfare programs.

Once the patient’s basic needs are met, the nurse makes return trips to the patient’s house to make sure he understands his post-discharge care plan. Together, they go over the dosages and timing of the patient’s medications, the recommended diet and exercise plan, as well as future primary care appointments. The home visits continue until the patient is empowered to manage his care effectively.

The CARE Network is showing signs of success. During the 2012 fiscal year, the CARE Network saw a 60 percent reduction in emergency room visits and a 40 percent reduction in hospitalizations for its patient population. CARE Network patients have a 21 percent lower 30-day readmission rate than QVMC’s overall patients—8.3 percent versus 10.5 percent.

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