Care Coordination


Mendonoma Health Alliance’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, Mendonoma Health Alliance 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 and consultation for individuals referred by a medical provider
  • Free free glucometer consultation & glucometers for individuals referred by a medical provider
  • 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 free fentanyl test strips
  • Access to free harm reduction safer injection kits
  • Access to durable medical equipment

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.

2024 © Mendonoma Health Alliance


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