In Care Coordination of Medically Vulnerable
Homeless Patients, Housing is a Form of Healthcare
Most patients discharged from the hospital ultimately return to a secure home environment. Not so for homeless or unstably housed patients; disconnected from healthcare and their community, their lack of stable housing compounds their medical difficulties following a hospital stay.
Enter Chronic Care Plus (CCP), a safety net recuperative care program in California whose mission is to bridge this gap between hospital discharge and permanent supportive housing for homeless patients, or "Joes," as Illumination Foundation Founder and CEO Paul Leon characterized his client profile during a recent presentation.
"I'm sure you can identify the 'Joes' in your neighborhood," Leon told participants during Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, a December 2016 webinar now available for replay. "They've come into the ER but are never quite connected with either a federally qualified health clinic (FQHC), your own hospital clinic or any available resources in your community."
In case you missed this webinar, you still have a chance to watch this highly-rated program.
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The CCP program not only provides housing for recently discharged homeless or unstably housed individuals in model or dormitory-like settings but also reconnects them to the healthcare continuum. The program then wraps clients in a plethora of services, including housing placement, financial literacy, job placement, transportation and behavioral health support.
Back in 2008, Leon's organization was one of only about seven in the nation to provide recuperative care (also known as medical respite care). Recuperative care is care to homeless persons recovering from an acute illness or injury, no longer in need of acute care but unable to sustain recovery if living on the street or other unsuitable place, Leon explained. Today there are about 80 such programs in the United States.
Since then, his foundation created standards and best practices, and in 2013 launched CCP—"recuperative care on steroids, with tightly wrapped social services and a longer length of stay," Leon explained.
Originating as an ED diversion pilot aimed at 20 of the highest users of a local hospital ER, CCP has transformed discharge planning for the homeless and has served more than 2,500 patients since its inception.
During the presentation, Leon shared a host of program analytics, including recuperative care criteria client demographics and CCP statistics on medical, behavioral health, housing and other services provided. He also shared CCP's future plans, and some of the program's barriers and challenges, including medical management education and closing gaps in social services.
In terms of program outcomes, CCP has amassed significant savings as it closes gaps in care and reduces healthcare utilization, including 322 fewer ER visits by this population (a 84.3 percent decrease) and $2.8 million in medical cost avoidance at three participating hospitals.
"For Orange County hospitals as a total, we estimate that there was $5.2 million of savings," added John Kim, grants director of the Illumination Foundation. "If we compare the year prior on an annualized cost basis, that comes to over $7 million of savings to Orange County hospitals."
You can "attend" this program right in your office for insight on how the program managed care and costs for the medically vulnerable. It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear more details on: transitioning care from recuperative care to long-term supportive housing; communication channels and patient touchpoints during care transitions; using community EMTs to assist in care coordination and care transitions; savings attributed to medical costs avoidance; and addressing the barrier of previous incarceration to receive permanent supportive housing and some community services.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, please visit:
You may also be interested in these care coordination resources from the Healthcare Intelligence Network: