Redwood Community Health Coalition's Complex Care Initiative

California

Redwood Community Health Coalition is a network of 17 community health centers, with over 40 sites in Marin, Napa, Sonoma and Yolo Counties. In collaboration with Partnership HealthPlan, the coalition developed and implemented three successful Complex Care Management pilots. Redwood’s care coordinators work closely with patients to facilitate care across medical settings, help meet basic needs, connect people with benefits and support services (like transportation, housing, nutritious food and legal services) and engage them in primary care. They also provide specialty clinics in acupuncture, dental cleanings, dermatology, endocrinology, family planning, HIV services, integrative medicine, mental health, neurology, obstetrics, women’s health, optometry, pediatrics, podiatry and rheumatology. This project is part of Robert Wood Johnson Foundation's Transforming Complex Care initiative. 

Partner Organizations

• West County, CommuniCare, Santa Rosa Community Health Centers
• Redwood Community Health Coalition
• Partnership HealthPlan
• Robert Wood Johnson Foundation

Target Population

High-cost Medicaid enrollees who have behavioral problems, mental illness, cognitive impairment, physical disabilities or multiple chronic conditions; elderly individuals who are frail or have multiple chronic conditions

Care Team

Registered nurse as case manager, "peer-coaches"

Timeframe

2013 - present

Results/ Studies

The Complex Care Pilots have resulted in statistically significantly reduction in hospitalization days and associated costs. 

Funding

Federal grant

Resources

Program website

Profile by the Center for Health Care Strategies, Inc. (2017)