Care Coordination

Description

MHA’s Care Coordination program offers support to individuals that have been referred to the program by their health care provider(s) or for those who self-refer for resource coordination relating to health care needs and Social Determinants of Health. The purpose of this program is to deliver the appropriate level of resources to help clients adhere to the care plans provided by their medical team, with a goal of achieving improved health outcomes. In doing so, MHA recognizes that many health care needs cannot be met if our clients’ basic human needs, such as food, economic resources, and social resources, are not being met. Our team of experienced Community Health Workers are able to deliver personalized and effective services by digging deeper with each client to discover underlying needs and leverage their knowledge of local, county, state and federal resources to meet those needs.
As a participant of the Care Coordination program, clients will receive education relating to their needs and learn skills to set health goals that are achievable. Throughout their work with clients, Community Health Workers utilize evidence-based approaches, such as Motivational Interviewing, to improve efficacy and teach clients how to become self-advocates.
Below is a list of resources or services that are provided through the Care Coordination program:
  • Review of care plan provided by medical provider to ensure clarity of all medical advice and to ensure the client has all of the resources required to follow the care plan
  • Free blood pressure cuffs for individuals referred by Redwood Coast Medical Services into our Remote Patient Monitoring program for hypertension
  • Free pill organizer boxes
  • Free prescription lock bags
  • Nutrition Education
  • Recipes for healthy cooking/eating
  • Prevention and management education for chronic conditions
  • Assistance with county, state and federal paperwork (e.g. CalFresh, housing documents, insurance paperwork, etc.)
  • Medication adherence review
  • Referrals to other resources, such as addiction treatment, behavioral health, and primary care
  • Assistance with food insecurity
  • Interpreter services for Spanish-speaking clients
  • Transportation coordination
  • Wellness checks (in-home spot check)
  • Access to free Naloxone/Narcan for individuals with pain medications or for those dependent on or living with individuals who consume opiates
  • Access to durable medical equipment
  • Temporarily – Financial Assistance for individuals financially impacted by the COVID-19 pandemic
  • Temporarily – grocery gift certificates and gas cards for individuals impacted by the COVID-19 pandemic

This website and MHA’s programs are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award through the Rural Health Network Development Program totaling $898,645 and through the Rural Communities Opioid Response Program totaling $1 million, over a 3-year period, with  80% funded by HRSA/HHS and 20% percentage funded by non-government source(s), such as the Arlene & Michael Rosen Foundation, Santa Rosa Memorial Hospital, the Community Foundation of Mendocino County and tax-deductible contributions from community members. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA/HHS or the U.S. Government.

2020 © Mendonoma Health Alliance

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