By RENEE STOVSKY
When Amelia Lacey, 57, arrived at the emergency room of Queen of the Valley Medical Center in Napa, Calif., in January 2012, with extreme abdominal pain, it was quickly determined that her bowel had ruptured as a result of advanced colorectal cancer. She was rushed into surgery, where doctors operated to remove tumors and perform a colostomy.
Recovery from such a major procedure would be difficult for anyone. But for Lacey, uninsured, living alone and facing chemotherapy, it was overwhelming. "I didn't know what I was going to do," she recalls.
Luckily, Queen of the Valley, part of the St. Joseph Health system, came to her aid. The hospital had begun an extensive community outreach program around 1990 to help less fortunate patients manage
HIV and AIDS. Through the years, it had evolved to include patients with cancer, heart failure, diabetes, renal disease, coronary artery disease, liver failure, chronic obstructive pulmonary disease and other chronic conditions.
Now called CARE (Case management, Advocacy, Resources and Education) Network, it serves 375 to 400 patients per year. By providing nurses, social workers, therapists, aides, and spiritual care, the program helps patients overcome barriers to managing serious illness.
Hierarchy of needs
"Our philosophy is that if someone is at risk of being homeless or having difficulty feeding themselves or their family, learning to manage a chronic condition is not going to be at the top of their priority list," says Dana Codron, executive director of the hospital's community outreach department. "We focus first on securing basic needs for these clients."
Often, she adds, those needs go beyond food and shelter. Many of the people referred to the CARE Network also are non-English speakers facing language barriers, or suffer from depression, anxiety or more serious mental health conditions as well.
In Lacey's case, Angie Mueller, a nurse and case manager, and Julie Penning, a social worker, met with her in the hospital to develop a plan to help her best manage her medical condition and new life circumstance.
"Amelia had been working as a caregiver, something she was no longer able to do. So my first priority was to secure an income stream for her through Social Security disability" benefits, says Penning. "We also started the paperwork to apply for MediCal," California's Medicaid program.
When Lacey was able to go home, CARE Network staff members offered practical and essential instruction to Lacey and her daughter, who stayed overnight with her mother when she could. "We made sure she had enough medicines and colostomy bags, and helped with timing and techniques," Mueller says.
Lacey's CARE Network team also helped her secure and move to a more affordable apartment in her senior housing complex. And they made certain she had access to nutritionally rich food to support her recovery.
Once Lacey's health stabilized, she began chemotherapy. Unfortunately, a CT scan showed that the cancer had metastasized to her liver. Lacey had further surgery at University of California San Francisco Medical Center, followed by more chemotherapy. Last December, she wound up in Queen of the Valley's intensive care unit, unable to fight off an infection due to her weakened immune system. At that time, a decision was made to suspend Lacey's chemotherapy.
Today, her condition is stable and a hospital spokesperson reports Lacey's doctor says she does not require chemotherapy at this time.
Seize the day
Lacey participates in the hospital's cancer wellness program, where she gets physical therapy, exercise supervision, nutrition education and massage, along with spiritual care. She attends meetings of the hospital's cancer support group and also has had short term behavioral health therapy through Queen of the Valley.
"I don't know what the future will hold, so I am concentrating on balancing two things: living it up as best I can, going to movies and eating popcorn with friends; and seeing a priest and planning my memorial service," says Lacey.
Lacey's CARE Network team continues to provide in-home supportive services; a caregiver visits her twice a week.
"This has meant so much to me. Julie and Angie are such great, neat people; they've helped me not only medically but emotionally," says Lacey. "I really feel like they are family."
Whatever it takes
Lacey's experience with CARE Network is typical, says Codron. "We strive to provide a tightly woven safety net for the most vulnerable and socioeconomically compromised. And though we hope to help clients achieve self-management within six months, we often provide intense services for a year or more and then provide links to other community-based support."
Aura Silva, a nurse who coordinates CARE Network, adds, "We help with transportation vouchers; we pay utility bills; we give the homeless prepaid phone cards so they can communicate with us and others involved in their care. If a client needs help with organizing medicines, we'll provide pill boxes. If a client has heart failure, we'll provide a scale so they can determine if they are retaining fluids.
"We've also helped people with child care access and after-school programming. We've bought school uniforms and shoes. When we realized a family was living in a garage and sleeping on the floor in sleeping bags, we were able to supply them with air mattresses," she adds. "We strive to enhance quality of life however we can."
Quality of life
In addition to lessening the burdens of vulnerable patients, Queen of the Valley has been able to reduce emergency room use by its CARE Network clients by 77 percent and hospitalizations by 40 percent. Those surveyed also showed a 90 percent increase in improved self-management and quality of life.
"It just so happens that St. Joseph's is finally seeing a return on investment with CARE Network," says Codron. "But the establishment of our program was originally rooted in our mission to focus on the most vulnerable and improve the health and quality of life in the community we serve."
"Our entire community outreach program budget has been 1.5 percent of the hospital's operating expenses for many years; of that CARE Network receives about $1 million, mainly for staff salaries to cover four nurse/social worker teams, plus aides, clerical help and administration. We also draw on emergency funds from donations made at an annual fundraiser," says Codron.
CARE Network has received national recognition, with a 2012 NOVA award from the American Hospital Association and a 2013 award from the Robert Wood Johnson Foundation.