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Service Delivery Innovation Profile

Short-Term Housing and Care for Homeless Individuals After Discharge Leads to Improvements in Medical and Housing Status, Fewer Emergency Department Visits, and Significant Cost Savings


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Snapshot

Summary

The Illumination Foundation’s Recuperative Care Program gives homeless clients the opportunity to rest in a safe environment after hospital discharge. Hospitals refer patients to the program, specify the appropriate length of stay, and pay a per-diem rate for program services, which include housing in a motel, food, medical care (from a nurse), and case management and connections to needed social services (from a social worker). An evaluation of the program found that the vast majority of those served remained stable or improved medically in the year after discharge, with the typical participant having significantly fewer emergency department visits. In addition, the program has found permanent housing for one-half of those served and has generated more than $11 million in savings for area hospitals.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the medical condition of program participants and their ED use in the year after discharge from the program, along with post-implementation data on the proportion of clients connected to permanent housing and the estimated cost savings for referring hospitals.
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Developing Organizations

Illumination Foundation
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Date First Implemented

2010
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Patient Population

Vulnerable Populations > Homelessend pp

Problem Addressed

After an acute injury or illness, homeless individuals typically do not fully recuperate because of various challenges associated with homelessness, such as unsanitary conditions and the lack of stable sources of housing, food, and followup medical care and social services. As a result, these patients often end up being readmitted to the hospital or return to the emergency department (ED). In California, State laws require hospitals to discharge patients to appropriate care, typically a residential facility that serves homeless individuals. However, few such facilities exist, often forcing hospitals to keep them in the hospital longer than necessary.
  • Many homeless individuals: The National Alliance to End Homelessness estimates that in 2010, nearly 650,000 people experienced homelessness in the United States, approximately 17 percent of whom were chronically homeless.1 Between 21,000 and 35,000 homeless people live in Orange County, CA,2 whereas roughly 50,000 homeless individuals live in Los Angeles County.3
  • Inability to recuperate from injury or illness: Many homeless individuals do not fully recuperate after an acute injury or illness. After discharge from the hospital or ED, these individuals usually do not have a clean, restful place to live or easy access to food, social services, or followup medical care and support. As a result, they find it difficult to recover.
  • Readmissions, return ED visits, or extended hospital stays: Homeless individuals experience twice as many readmissions and more than twice as many inpatient days when they are discharged back to the streets rather than to respite or recuperative care.4,5,6 To address these and other issues, California Health and Safety codes regulate the discharge of patients who receive emergency or inpatient treatment to appropriate posthospital care, which for homeless individuals typically means discharge to a residential facility.7 Codes dictating the appropriate discharge of homeless individuals include California Health and Safety Codes 1262.5, 1290, and 1262.4; Los Angeles Municipal Code 41.60; and Penal Code 368; in addition, the Los Angeles County Ordinance 179913, passed May 16, 2008, made it illegal for hospitals to discharge a homeless patient to the street without consent and prohibits other cities from “dumping” homeless patients in Los Angeles. To comply with these codes in the many instances when residential beds are not available, California hospitals often end up keeping homeless individuals in the inpatient setting for days after they are otherwise ready to leave, with the cost of each additional day estimated at $2,279.4
  • Unrealized potential of recuperative care: Although recuperative care programs offer a viable alternative for these hospitals and have been shown to reduce readmissions and ED visits for recently discharged homeless patients, few such programs exist in most cities.4

What They Did

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Description of the Innovative Activity

The Illumination Foundation’s Recuperative Care Program gives homeless clients the opportunity to rest in a safe environment after hospital discharge. Hospitals refer patients to the program, specify the appropriate length of stay, and pay a per-diem rate for program services, which include housing in a motel, food, medical care (from a nurse), and case management and connections to needed social services (from a social worker). Key program elements include the following:
  • Referral process and payment: The Recuperative Care Program contracts with 61 hospitals that discharge patients to either of 2 program sites (in Orange County and Los Angeles). Hospitals fax a one-page referral form that provides relevant patient information including recuperative care needs, such as appropriate diet and medical equipment to support ambulation. Clients must be independent, able to perform activities of daily living, and referred to recuperative care for acute (nonchronic) conditions with an endpoint of care; exclusion criteria include urinary and bowel incontinence, active substance abuse, combative/aggressive behavior, and unstable medical or mental status. The form specifies the number of days the hospital authorizes the patient to stay in the program, which can range from 3 days for those with small medical issues (e.g., a minor infection) to 60 days for those with more severe problems (e.g., a broken leg). The typical patient stays 10 to 14 days. Hospitals pay the program $200 per day for various services designed to facilitate recovery, as outlined in the following bullet.
  • Broad array of recuperative services: The program offers a broad array of services to facilitate recovery, including housing in a motel, food, nurse-led medical oversight, case management, and connections to needed social services.
    • Housing in motel: The program rents blocks of rooms in 2 motels—35 rooms in a motor lodge in Orange County and 20 rooms in a motel in Los Angeles. A site coordinator works full time at each motel, helping patients check in and providing for the room, board, and transportation needs of the client.
    • Nurse-provided medical oversight: A nurse assesses each patient to identify needs, including those that might not have been included in the hospital discharge plan, such as medical followup appointments, oversight of home health coverage, and mental health needs. Through visits three times a day, the nurse provides appropriate care and oversees the patient’s medical condition(s) throughout the stay, including reviewing his or her medication regimen and making sure that medications are taken appropriately. As needed, the nurse connects the patient to medical insurance or a medical home, provides assistance with scheduling followup appointments with physicians, and provides patient education.
    • Case management/social services: A social worker serves as a case manager, providing or arranging for services to help clients remain stable after leaving the motel. The social worker conducts an initial psychosocial assessment and then organizes services accordingly, such as helping clients obtain an identification card; assisting them in applying for food stamps or Social Security benefits; or arranging for needed mental health care, transportation to medical and social service followup visits, and housing and legal assistance. Social workers attempt to find permanent housing at apartments, long-term sober living programs, family reconciliation, housing projects, and "board and care" facilities.
    • Food and other services: Each room has a small refrigerator and microwave oven. The site coordinator purchases healthy groceries and delivers them to the patients. The program can handle special diets required by patients’ specific needs, such as accommodating food allergies or providing low-sugar diets for those with diabetes. The site coordinator also helps identify and meet other needs, such as getting a haircut and doing the laundry.
  • Discharge and followup: At the end of the designated time, the program provides a "warm handoff" to safe housing or shelters. Program staff call the new site after 1 week to check on the individual’s well-being and inquire about his or her medical needs. Patients may only remain at their housing location for a short time, making long-term followup more difficult. However, the program offers brunch every Sunday at the motel sites, and former patients frequently attend to eat and visit with staff. During these lunches, they often provide an update on their status and request any additional assistance they may need with medical care or social service connections.
  • Communication and followup with referring hospitals: The program provides discharge planners at the referring hospitals with two reports on each patient—one halfway through the stay and one at discharge. The first report outlines identified medical and mental health needs, services provided to date, and patient adherence to the hospital discharge plan (including medication compliance). The second report provides a summary of the care provided under the program and notes the patient’s next destination.

Context of the Innovation

The Illumination Foundation is a nonprofit corporation that provides services to the homeless in the city of Los Angeles and Orange County, CA. The impetus for this program came from foundation staff, who in their efforts to link homeless individuals to community-based medical services found that hospitals often did not have a safe, reliable place to discharge these individuals, which had a negative impact on their ability to recuperate. Encouraged by the leaders of hospitals in the area (which were trying to comply with State laws requiring them to discharge homeless patients to an appropriate setting), the Foundation created the Recuperative Care Program to fill this gap in services.

Did It Work?

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Results

The vast majority of those served by the program have remained stable or improved medically in the year after discharge, with the typical participant using significantly fewer ED services. The program has found permanent housing for one-half of those served and has generated more than $11 million in savings for area hospitals.
  • Stable or improved medical condition: An analysis of 1,294 individuals served by the program found that 85.2 percent remained stable or experienced improvements in their medical condition during the year after discharge.
  • Less ED use: The same analysis found that program participants experienced a 39.4-percent decline in ED use in the year after discharge compared with the year before program enrollment.
  • Stable housing for many: Since 2010, one-half of all clients have been connected with transitional or permanent housing.
  • Meaningful savings for referring hospitals: The analysis highlighted above found that area hospitals saved roughly $11.1 million as a result of the program, as they no longer had to keep patients in the inpatient setting longer than necessary.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the medical condition of program participants and their ED use in the year after discharge from the program, along with post-implementation data on the proportion of clients connected to permanent housing and the estimated cost savings for referring hospitals.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Winning hospital contract: A hospital in Orange County, St. Joseph's Health System, distributed a request for proposals to organizations interested in providing recuperative care services to the homeless. The Illumination Foundation received the contract to provide such services, and the National Health Foundation and the Hospital Association of Southern California were designated to serve as contract administrators.
  • Meeting with hospital administrators: Program leaders held multiple meetings with hospital chief executive officers and chief financial officers to highlight program services, present the business case for their participation (including estimates of potential cost savings for hospitals), and negotiate contracts with those hospitals that expressed interest.
  • Meeting with discharge planners: Program leaders met with hospital-based discharge planners to develop the process for discharging homeless patients to the program, including a user-friendly discharge form. On an ongoing basis, they host a quarterly conference call with discharge planners to ensure that the program continues to meet their needs.
  • Contracting with motels: Program leaders met with managers and owners of various local motels to negotiate arrangements to rent a block of rooms on an ongoing basis. For some rooms, the foundation paid to install tile floors (to replace worn-out carpets) and new, sturdier beds and mattresses.
  • Plans for expansion: Program leaders plan to open an additional motel site in Los Angeles County by mid-2013.

Resources Used and Skills Needed

  • Staffing: The program employs 11 individuals on a full- or part-time basis. A full-time director oversees the program, supported by a part-time medical assistant and full-time administrative assistant. Each site has a full-time nurse, social worker, and coordinator. The program also has three part-time staff who help on weekends and as needed during busy periods.
  • Costs: Development costs included a moderate investment to renovate some of the motel rooms. Ongoing costs include the salary and benefits of program staff, room and board for patients, and occasional repairs to damaged rooms. The hospital per-diem payment of $200 is adequate to cover all program-related costs.
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Funding Sources

Illumination Foundation
The Illumination Foundation funds the program out of its operating budget; as noted, referring hospitals pay the foundation $200 a day for program services.end fs

Tools and Other Resources

A toolkit on respite care produced by the National Health Care for the Homeless Council is available at: http://www.nhchc.org/resources/clinical/medical-respite/tool-kit/.

Adoption Considerations

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Getting Started with This Innovation

  • Evaluate benefits of using motels: Use of motels to provide temporary shelter to newly discharged homeless individuals requires little or no upfront investment in fixed assets. Motels allow for flexible capacity, with security and maintenance provided by motel management.
  • Emphasize benefits for hospitals: In communications with hospitals, emphasize the program's potential benefits, including its ability to help them comply with legal requirements to discharge homeless patients to an appropriate setting at low cost (versus the much higher cost of keeping them in the hospital until a safe discharge location can be identified). This benefit will be especially important for hospitals that consistently run at full capacity, as each freed-up bed can be used by other (presumably revenue generating) patients. In addition, emphasize the program's flexibility (e.g., there is no need for hospitals to commit to a minimum number of referrals) and the public relations benefits of partnering with this kind of program.
  • Recognize motel owner concerns: Motel owners may initially be reluctant to participate, especially given the medical and mental health problems experienced by many patients. To overcome these concerns, stress the financial benefits of having a stable, reliable source of room rentals and the presence of onsite program staff to monitor patients. It might also be helpful to engage motel owners in the noble mission and purpose of the program.
  • Allot funding for room repairs: Mentally ill patients may damage rooms on occasion, thus creating the need to set aside funds to finance repairs when necessary.
  • Make referral process easy: Make discharging patients to the program easy for hospital-based case managers and social workers. To that end, design a short, basic discharge form and be available to respond to questions. These steps will make discharge planners more likely to use the program and ensure that patients can be moved quickly to a recuperative care setting when they do.
  • Define scope of service: Understand which types of patients can be adequately cared for by the program. For example, patients with extensive medical and mental health needs may be better served in a skilled nursing facility, rehabilitation center, or other more intensive setting.

Sustaining This Innovation

  • Rely on per-patient funding: Relying on grant funding can be risky. Instead, consider charging a per-diem rate high enough to cover program expenses but well below the costs of keeping the patient in the inpatient setting. This approach will make the program attractive to hospitals (which stand to save significant amounts of money), thus ensuring a steady stream of referrals and a sustainable source of program funding.
  • Evaluate and refine program on ongoing basis: Program leaders should periodically reevaluate the needs of patients and hospitals, particularly in response to changes in the area housing situation, regulations, and medical issues facing the homeless (e.g., outbreaks of tuberculosis). To that end, program leaders should maintain formal and informal communications with hospital discharge planners to ensure that the program responds in a timely manner to any changes in their needs.

More Information

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Contact the Innovator

Aiko Tan
Director of Recuperative Care
Illumination Foundation
2691 Richter Avenue, Suite 107
Irvine, CA 92606
(760) 443-8974
E-mail: atan@ifhomeless.org

Innovator Disclosures

Ms. Tan reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

The Illumination Foundation. Recuperative Care Program Profile. Available at: http://www.ifhomeless.org/about-if/services/recuperative-care-program.

Fader HC, Phillips CN. Frequent-user patients: reducing costs while making appropriate discharges. Healthc Financ Manage. 2012;66(3):98-100, 102, 104. [PubMed]

Phillips CN. Homeless patient discharge planning: best practices for frequent flyers, part 1. CCH Health Care Compliance Letter. 2010;4-6.

Footnotes

1 National Alliance to End Homelessness. Helping chronically homeless people avoid high-cost health care. Federal Policy Brief. Washington, DC. 2011 Aug. Available at: http://www.endhomelessness.org/library/entry
/helping-chronically-homeless-people-avoid-high-cost-health-care
.
2 The Illumination Foundation. Available at: http://www.ifhomeless.org/.
3 Lin R, Zavis A. Homelessness in L.A. County falls 3%, survey finds. The Los Angeles Times. 2011 Jun 15. http://articles.latimes.com/2011/jun/15/local/la-me-0615-homeless-count-20110615.
4 Fader HC, Phillips CN. Frequent-user patients: reducing costs while making appropriate discharges. Healthc Financ Manage. 2012;66(3):98-100, 102, 104 passim. [PubMed]
5 Buchanan D, Doblin B, Sai T, et al. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96(7):1278-81. [PubMed]
6 National Health Care for the Homeless Council. Medical respite care: reducing costs and improving care. Policy Brief. Nashville (TN). 2011 Apr. Available at: http://www.nhchc.org/wp-content/uploads/2011/09/RespiteCostFinal.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
7 Phillips CN. Homeless patient discharge planning: best practices for frequent flyers, part 1. CCH Health Care Compliance Letter. 2010 Nov 2;4-6.
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Original publication: October 23, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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