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Dominican Hospital Partners with Local Organizations to Provide a Continuum of Care for the Most Vulnerable in Our Community


Passport to Health program provides a holistic approach to care for local residents

SANTA CRUZ, CA (April 19, 2018) – Dignity Health Dominican Hospital has partnered with a collaborative of local medical and service organizations to help some of our community’s more vulnerable populations gain access to primary care, behavioral health services, and social services outside of the emergency room.

The Passport to Health (P2H) program unites Dominican Hospital with primary care, mental health, substance abuse, and housing agencies from across Santa Cruz County in an organized health care arrangement to address community needs in a highly coordinated way. This quality improvement initiative identifies individuals who use the hospital’s emergency department most frequently, and aims to connect them with intensive case management along with navigation to social resources in the area.

“One of the biggest health care challenges facing any community is identifying the range of patient needs and creating a continuum of care to assist them outside the hospital,” says Dominican Hospital President Nanette Mickiewicz, MD. “The work of the Passport to Health program is helping us address this challenge head on, to ensure that no one in need of ongoing support falls through the cracks.”

“At Dignity Health, we are interested in the bigger picture. We are as invested in the care a patient receives outside hospital walls as we are within them,” explains Dignity Health Vice President of Community Health Pablo Bravo. “With the Passport to Health program, we are looking upstream to see exactly what is triggering health issues in these high-need populations and precisely where there are gaps in care. Together, we are filling those gaps.”

Regular tracking of how these patients use health care services, coupled with intensive case management at the clinics where they receive care, can help reduce expensive visits to the emergency department. This in turn increases more consistent visits with primary care physicians, improving overall health and reducing health care expenses. 

Key components of the P2H program include identifying high-need individuals and sharing information among P2H providers and agencies for referrals and appropriate care and services, to ultimately measure health care usage and cost outcomes. This information enables the program to make sure each individual identified benefits from a comprehensive network of care. It also allows P2H members to accurately track the efficacy and progress of the program.

The P2H initiative was launched through seed funding from a Dignity Health Social Innovation Partnership Grant, with additional organizing support from the California Central Alliance for Health and Dominican Hospital.

“The Passport to Health program is guided by local innovation,” says Central California Alliance for Health Chief Medical Officer Dale Bishop, MD. “Each participating organization is led by a team of experts and change agents. In bringing these dynamic partners into seamless collaboration, we are assured of an initiative that will deliver real results for this population in need.” 

Program delivery wouldn’t be possible without the group of local medical and service organizations providing support through the Health Improvement Partnership of Santa Cruz County. They include Encompass Community Services, Homeless Services Center, Janus of Santa Cruz, Santa Cruz Community Health Centers, and Santa Cruz County Health Services Agency. The Passport to Health program is the culmination of concentrated planning by these organizations, which began in 2016. “The Passport to Health program represents truly collective action to heal and house the most vulnerable in our community,” says Health Improvement Partnership Executive Director Elisa Orona. “The creative leadership in Santa Cruz County is continually inspiring. We are making meaningful and measurable change possible.”

About Dominican Hospital

Dignity Health Dominican Hospital has been caring for the Santa Cruz County community for 75 years. Dominican offers emergency services and is a Certified Stroke Center. Dominican’s services include the only comprehensive Cancer Center in Santa Cruz County, a Total Joint Replacement program, advanced neurological and endoscopic services, and an expert heart and vascular team treating some of the most complex cardiac cases in the Monterey Bay area. Dominican has received national recognition for superior patient safety, cardiac care, and stroke treatment from Healthgrades, a leading provider of comprehensive information about physicians and hospitals. Dominican also has received several awards for environmental excellence.


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