Care Transitions

Description

Care Transitions is an evidence-based program intended to help individuals experience a smooth transition back home after being discharged from the hospital. Our experienced Community Health Workers (CHWs) are linked to a variety of resources and services that ensure that each client has what they need in order to adhere to the directions of their medical team. The one-on-one support provided by CHWs helps clients remain healthy and comfortably at home while reducing readmission to the hospital. Mendonoma Health Alliance’s Care Transitions program has proven to be successful. Only 7% of the clients using our program have readmitted to the hospital, compared to the Sonoma County and Mendocino County hospital readmission average of 14.3%.

This service is designed to follow clients for 30 days after the date of hospital discharge. While engaging in the program, CHWs use a variety of evidence-based teaching techniques, such as Motivational Interviewing, to help clients learn how to become self-reliant and confident in advocating for their own health. Care Transitions is available for any person who is being discharged back home into Mendonoma Health Alliance’s Service Area regardless of their diagnosis.

Mendonoma Health Alliance does not provide medical services and Care Transitions is not intended to replace medical care. Instead, its purpose is to work in collaboration with medical providers to deliver the most robust wrap-around care possible for clients to become educated, empowered and self-advocates so that they can properly manage their recovery and/or conditions at home in between primary care and specialty care appointments.

CHWs can assist with medication adherence, transportation, coordinating follow-up visits, connecting clients with needed services, in-home care management resources (blood pressure cuffs, pill boxes, prescription medication lock bags, Narcan, etc.), preparing for medical appointments, and much more. Throughout this short-term service, CHWs can also help individuals access food, food programs and provide direction for applying for various federal, state and county programs.

For more information on the Care Transitions Program, please contact us at (707) 412-3176 x101, or use the Referral Form on the right-hand side of this page to send an inquiry directly to Mendonoma Health Alliance staff.

Services are available in Spanish. For bilingual services, contact Stephanie Chapman (CHW) at (707) 412-3176 x106.

Download Referral Form

Picture of hispanic old couple, sitting in a home or office setting, with younger woman looking at a piece of paper being held by the man. Younger woman is explaining paperwork with a pen in her hand. This is a Care Transitions Ad for Mendonoma Health Alliance Spanish speaking clients.

This website and Mendonoma Health Alliance’s programs are partially supported by the California Department of Public Health as part of a grant award through the Substance and Addiction Prevention Branch totaling $1,281,000 over a 3-year period that began on March 1, 2024. Other funding sources that support this website include funding from Santa Rosa Memorial Hospital’s Community Benefit Program and generous donations from the community. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CA Department of Public Health.