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CARE Network - Transition to Better Care

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Published on Nov 16, 2012

The CARE Network (Case Management, Advocacy, Resource/Referral, Education) provides a continuum of care transition from hospital to home followed by community based chronic disease management support. Services focus on vulnerable populations, particularly those patients with complex medical conditions as well as difficult socio-economic needs such as housing insecurity and basic needs deficits. The program involves a community and hospital partnership that strengthens local systems of care to improve health conditions and quality of life among these patients and reduce health care costs through better coordination, continuity of care, timely enrollment and access to public assistance programs and community services and health care access. The program utilizes an interdisciplinary approach with RN/Social Work teams, care aids, and behavioral health specialists. For the nearly 400 patients served in in FY 12, CARE Network clients demonstrated a 60% decrease in emergency room visits, and a 53% decrease in hospitalizations.
C - Case Management

A - Advocacy

R - Resource & Referral

E - Education

We promote independence in self-management of chronic conditions through home visits by nurses and social workers offering comprehensive support and case management services.

For more information or referrals, call 707-251-2000.

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