CARE Network
At Queen of the Valley, our Case Management Advocacy Resources Education (CARE) Network provides the full spectrum of support for patients who, for one reason or another, don’t have access to the financial, educational, emotional or other resources they need to care for themselves. Support services under the CARE Network umbrella include assistance with:
         • Disease education (including coping and decision-making)
         • Medication compliance and adherence
         • Benefits, financial and community resources
         • Limited social or family support
         • Home safety concerns
         • Over- or under-utilization of medical services

CARE Network services are available to all low-income, uninsured or underinsured Napa County residents living with a chronic condition and who would benefit from case management services. For example:
         • Heart Disease
         • Lung Disease
         • Cancer
         • HIV/AIDS
         • Diabetes
         • Other Chronic Conditions

A brief case study might be the best way to explain how the Network operates.
When we (CARE Network RN and Social Worker) first met Connie she was depressed, reclusive and no longer connecting with the community around her. At the age of 55, her blood sugar was extremely high and she did not have the motivation to consistently manage her condition. She experienced frequent chest pains and regularly spent time in the Emergency Department. Connie also had significant financial challenges, and she often had no food in her home.  During our first home visit with Connie, she sobbed nearly nonstop.

Her most immediate needs were nutritional. CARE Network immediately brought food into Connie’s home, provided her with food cards, and referred her to the local food bank. We assisted her to schedule follow up medical appointments and arranged transportation to get her to and from these appointments. We also referred Connie to our behavioral health specialist for in home therapy sessions to help with her depression and ability to resume managing her disease and life in general. Simultaneously, a CARE Network nurse began educating Connie about her chronic conditions. Since connecting with the Network, Connie has made remarkable progress. Her chest pains are much less frequent, and her energy has improved. Comprehensive, coordinated support is the key to continuing her recovery and preventing relapses.

When she began feeling better Connie was agreeable to enroll in our Medical Center Cardiac Rehab Program, and has been participating consistently. Connie has lost 10 lbs, has made new friends and increased her endurance and strength. She now monitors her blood sugar regularly - and her sugars are now within normal ranges.

As a result of coordinated behavioral health therapy, Connie is much less distressed and her cognitive skills have improved greatly. She is less depressed, has joined a church and is getting out into the community more. In all, Connie’s trips to the Emergency Department have decreased by 32% since she has enrolled in the CARE Network.

Connie did not understand her Medicare insurance and was often left without coverage for medications when the “rules” changed. For example, the pain medication she had been on for years suddenly cost $700.00/month. CARE Network worked with the local FQHC and Wal-Mart to keep her prescription filled. They then negotiated with HICAP to switch her to a plan that offered improved coverage for her medications and access to care. They also obtained a new and improved breathing assistance device to better treat her sleep apnea and Connie got the first full night’s sleep she’d had in 10 years.

When Connie became very ill with pneumonia, she phoned an ambulance. She was hospitalized and upon discharge was threatened with eviction due to building code violations discovered subsequent to her ambulance response. Staff connected her to legal aide and housing authority. She was not fined and was not evicted.

A CARE Network social worker helped Connie get back on track financially by helping her to obtain benefits that covered her medications. They also helped her apply for charity care to help pay her medical bills, and assisted her to register for discount utility programs and other appropriate resources.

The CARE Network extended the umbrella to Connie’s brother, as well. He suffered from bipolar disease and had been ill and homeless for a long time. Through the CARE Network, he was referred to a local housing program for mentally ill, homeless individuals and he now has housing and access to psychiatric care.

Connie calls her CARE Network caregivers her “guardian angels.”

Funding for the Queen of the Valley CARE Network is provided through the St. Joseph Health System Foundation.    Top