BOY, has El Dorado County made strides in caring for our homeless population. The following is an update from those from Marshall Medical Center who have taken on the burden of caring for our homeless population.
Care Coordination for Vulnerable Populations (CCVP)
Population Health Division
Shaunda Crane, RN, MS, PHN, CWCN, S-FNP
Director of Care Coordination for Vulnerable Populations
August 2020 OVERVIEW: Care Coordination for Vulnerable Populations (CCVP) is an expansive interdisciplinary program Led by Marshall Medical Center, strategically reaching our most vulnerable populations in El Dorado County. These navigation support programs reach those that present the highest risk for health complications, unmanaged chronic conditions, and other social complexities that impact all in the county. To date, multiple projects are established and growing.
The Director of CCVP, Shaunda Crane, RN, MS, WOCN, S-FNP, has established and oversees multiple programs for Marshall Medical Center and Et Dorado County that align with El Dorado County’s Community Health Needs Assessment and strategic plan that was presented in January of 2020.
GOALS: 1. Provide coordinated care to vulnerable/low income populations such as our unsheltered/homeless, the elderly, women, and latino communities 2. Increase community collaboration in mental, behavioral and physical health, support family planning, coordinate effective social services, and improve environmental outcomes in our communities.
Team in the field
State Program; Project; Roomkey & Navigation Program: The state funded motel housing program for the most at-risk homeless populations likely to suffer dire consequences and incur significant medical costs if they are positive for the Covid19 or another complication. El Dorado County supports CHWs, the Sheriff’s Department and the Navigation Program, incorporated into Project Roomkey to further support our most vulnerable.
Marshall Medical Center: Community Health Workers (CHWs): Trained community volunteers who support and guide our most vulnerable populations related to securing health insurance coverage, income, housing and all that impacts such areas for success.
Multi-visit patients (MVP): Identification of the highest utilizers of the Emergency Department that could have been managed at an outpatient/community outreach capacity.
AUGUST HIGHLIGHTS FOR OUR COMMUNITY:
3 unsheltered individuals have found long-term housing.
16 unsheltered individuals are “document ready” for long-term housing.
2 women have successfully coordinated appropriate family planning.
1 elderly woman has successfully found safe housing.
4 CHWs have been trained on HMIS.
11 CHWs are coordinating with county and veteran agencies successfully.
OPPORTUNITIES FOR IMPROVEMENT: The cost of the current Care Coordination program is very low. Through one program director, 11 volunteers and engagement from multiple agencies, the only additional expense is related to wound care supplies and transportation costs. Lack of transportation to and from medical, legal and other appointments is an ongoing barrier for our vulnerable populations in a rural county such as El Dorado. The program needs vehicles in which designated drivers could help clients travel to and from appointments, receive wound care and other health assessments could be administered privately, and confidential areas are available for clients to engage in the support they are seeking. Further, the program will be more effective and efficient if a grant specialist is regularly engaged.
We give a special thanks to Dr. Martin Entwistle, Administrator of the Marshal Medical Center under whom this program flourishes.