Creating a continuum of care for highly vulnerable populations

June 01, 2019

James, a 55-year old man with Type 1 diabetes and a dependency on alcohol, was admitted to the emergency room for a collapsed lung following an assault. Like many homeless individuals, after his hospital stay, he was not yet strong enough to return to his unsheltered living situation and lacked other options for safe recuperation. To address this kind of need, St. Joseph Health in Northern California provides both respite care and social service support programs to ensure a continuum of care for the chronically homeless and vulnerable populations.

NCACBNews1“We have a deep history in our communities of helping the vulnerable, those who are low income and with chronic illness,” says Dana Codron, Regional Director Community Health Investment, St. Joseph Health Northern California. “Our communities have seen a surge in persistent homelessness in the past five years. In alignment with our mission to serve the vulnerable, our ministries have responded by supporting shelter and housing options, behavioral health services and a full scope of follow-up care management outside the walls of the hospital.”

In 2018 alone, SJH Northern California supported respite and care management programs with $5,762,752 of community benefit funding. This includes $3,777,936 for CARE (Care management, Advocacy, Resource referral and Education) Network, a community based program for low income chronically ill including the homeless and $761,412 for shelter facilities providing respite care for homeless or poorly housed patients after they are released from the hospital.

A place to rest, recover and get resources

In Napa, Humboldt and Sonoma counties, St. Joseph Health funds and supports respite programs helping many patients transition to better living situations. For people like James, having a place to recover will likely reduce his chances of returning immediately to the emergency room or being hospitalized with complications.

NCACBNews2During a stay of approximately 20-30 days, vulnerable patients are provided medical education and coaching along with care management services that assist them with housing options, financial assistance, primary healthcare access and medication management. In helping individuals with the options for a better life, these programs are reducing hospital readmissions and overall lengths of stay in the hospitals.

In Humboldt County, Providence St. Joseph Health has partnered with the Betty Kwan Chinn Homeless Foundation to open 10 additional medical respite beds for homeless patients after discharge, for a total of 17 medical respite beds in 3 locations. In 2018, Humboldt respite programs admitted 122 individuals and logged 1,981 respite bed days. Serving Sonoma and Napa Counties, Nightingale recuperative respite facilities have a total of 24 beds in 3 locations serving 250 people last year. These centers were originally designed by Catholic Charities of the Diocese of Santa Rosa in partnership with the Sonoma County Department of Health, Kaiser, Sutter and St. Joseph Health and expanded to Napa in collaboration with area hospitals, County HHS and the Gasser Foundation.

Building trust, connecting for Care

Supporting these patients doesn’t stop with temporary shelter. To ensure a continuity of care, the St. Joseph Health’s CARE Network actively supports individuals admitted to the respite programs with follow-up care appointments, help in obtaining social services, housing, food, clothing or other human needs. In Humboldt, 70% of those admitted completed their respite stay and follow up medical care. Of those completing care, 78 percent transitioned to more stable housing than they had prior to their hospitalization. In James’ case, a social worker and nurse, part of the CARE Network team, attended many follow-up doctor visits and connected him with housing and other community resources. In Sonoma, PSJH Mobile Care Team visits Nightingale facilities and other shelters such as Redwood Gospel Mission and Samuel Jones to provide clinical care. Humboldt and Napa CARE Network teams work in partnership with the local FQHC’s to assure appropriate and timely follow up primary care.

The CARE Network consists of social workers, nurses and community health workers who partner with the places and organizations where homeless and precariously housed individuals are found including emergency rooms, community health centers, respite facilities, hospitals and local homeless shelters. CARE Network members foster a sense of trust that is often necessary for these individuals to ask for or accept the help they need.

“In collaboration with our community partners, CARE Network care managers provide the glue that connects the continuum of care for this population,” says Codron. “Being on site in respite facilities unlocks the door to move people from the street to a better quality of life. Our CARE Network teams identify critical needs and assist individuals to build a stable future, including applying for social security disability income, accessing stable housing, food and other basic needs, ensuring access to medical treatment for mental health and substance use disorders and linkage to primary care. This work may continue well beyond the respite stay to ensure stability. One of the key things we learned over the years,” she says, “is that the most complex populations are often the most difficult to engage in care and services. It’s important to meet people where they are, ask them what their needs and goals are and in doing so we gain their trust to further assist them with other needs.

Supporting respite care and providing care management services, St. Joseph Health not only helps those who are most vulnerable in our ministries, but also reduces the health care burden in our communities. Persons served by the medical respite program at St. Joseph Hospital, Eureka and Redwood Memorial Hospital, Fortuna, had a 4.6 percent readmission rate in 2018 compared to the standard hospital readmission rate of approximately 12 percent. In Sonoma, persons served by CARE Network had a 5.7% readmit rate. For those served by in Napa CARE Network, ED visits decreased by 74% and hospitalizations decreased by 46% as compared to one year prior to enrollment.