Sacred Heart Health System

MyGULFCare Meets Clients Where They Are, Ensuring Access to Needed Health Care Services

Port St. Joe, FL

Not-for-Profit Hospital

19 Beds

MyGULFCare helps low-income Gulf County access needed health care services using a non-traditional, individualized approach. Offered by Sacred Heart Hospital on the Gulf, in partnership with the Florida Department of Health in Gulf County, MyGulfCare strives to improve the health of Gulf County residents by coordinating care between primary care physicians, the emergency department, the Department of Health and specialty care providers.

The program launched in 2012 with initial grant funding, and uses four components to meet local health care needs: chronic disease care management, prescription assistance, specialty referral coordination, and emergency department navigation.  While each component is critical, what makes the program successful is the team of care managers, a social worker, and a navigator that meet community members where they are.  Many meetings take place in non-traditional settings, which may include in-home visits, the grocery store, during an afternoon walking club, at the local food distribution site, or temporary housing for homeless clients.


“So satisfied. Off insulin completely after taking it four times a day for 25 years. I have lost 20 pounds too.” -MyGULFCare Client

The program exclusively serves low-income individuals who are either uninsured or underinsured.  It is clear that there is a need to meet not only chronic health needs, but access to other health and social services, as well individual education empowering clients to take control of their health and wellbeing. Home visits allow MyGULFCare team members to know clients personally, and understand their perspectives and current situation.  Clients and MyGULFCare representatives build trust and work together to address health and personal challenges.

One client referred to MyGULFCare was suffering from hypertension with comorbidities of depression, Post Traumatic Stress Disorder and obesity.  At the time of enrollment, he weighed 489 pounds, was not taking his blood pressure medication and became suicidal.  The care team secured access to the mental health care needed, and after his recovery he became fully engaged in the program’s Healthy Changes and participated in self-care management.  He has lost 100 pounds, his blood pressure is controlled, his diet and exercise have improved, and he now has a full-time job and is more active in his family.  According to him, “MyGULFCare saved my life.”

“This program and the Care Manager has been a great blessing. Helped us with housing too.” -MyGULFCare Client

Many other clients offer similar stories.  One woman was hospitalized for diabetic ketoacidosis after she passed out at work.  Thanks to her Healthy Changes plan, her blood sugar is under control, she no longer needs insulin, she has lost 15 pounds and has returned to work.  Another diabetic client attended Care Management sessions and implemented life changes that resulted in significantly improved blood sugar in less than three months.  He has now become a model client, and participated in a group health coaching session for active and graduated managed care clients where he enthusiastically shared his tips for healthy eating with other participants.  Other clients offer a different side of the story, as MyGULFCare care managers helped them reduce reliance on medication and make healthier choices so that they no longer had to choose between paying for prescription medication and utilities or food.

The MyGULFCare program currently has 154 active clients. In 2014, the program’s chronic disease care management program served 250 individuals. Clients experienced a dramatic reduction in blood sugar, body mass index, blood pressure and weight.  The prescription assistance program helped approximately 475 individuals receive free medications, and through referral coordination over 2,500 appointments were made for clients to see specialists (such as gastroenterology and cardiology), dental care, hospice, home health, radiology, lab, and other services.  In addition, in 2014 approximately 700 people were assisted through the emergency department navigation program. When the program began, some patients routinely used the emergency department for routine care, some as many as 30 times in one year.  By helping patients establish a medical home, make follow-up appointments with a primary care physician and access relevant social services, these clients now enjoy improved health and a strengthened overall quality of life.