Photos by Brock Stillmunks
Whether home means an improvised living space, a dedicated shelter or couch surfing, the homeless often seek primary health care in ERs. But admitting the homeless as patients poses a problem. Even after treatment, their hospital stays may extend in lieu of a stable home for post-acute care recovery. Hospital beds get tied up in the process. That’s an issue anytime but is especially challenging in a tripledemic. In response, the Charles Drew Health Center and Siena Francis House launched the Health & Dwelling Medical Respite Program, which includes sending a Charles Drew mobile unit to visit Siena’s campus twice a week.
The 24-month pilot program, which began in August, stems from an area Health & Housing Coalition that charted how well-being is adversely affected by unstable housing, making follow-up care problematic and resulting in high re-admissions. A task force from Siena Francis, Charles Drew, CHI Health, The Wellbeing Partners, Metro Area Continuum of Care for the Homeless (MACCH), CyncHealth and Unite Nebraska put data behind “a problem that has long been known to us,” said CHI Chief Medical Officer Dr. Cary Ward.
Joy Doll, formerly with Project Homeless Connect Omaha and now vice president, community programs, at CyncHealth, noted “growing community concern that hospitals essentially house people at a very expensive rate and shelters call ambulances for guests recently released from the hospital and send them right back for care.”
“From the patient perspective,” she added, “there’s not much dignity or positive experience in that. Everyone in the homeless continuum of care knew about this situation and no one felt good about it.”
The medical respite program is a “safety net” addressing the issue, Doll said, at a time when COVID-19, RSV and flu cases overwhelm medical facilities.
“Outpatients in the hospital who don’t need to be make it much more difficult to get people in that need to be hospitalized,” Ward said. “Hospitals want to keep those beds open and have them only for people who truly need hospitalization. That’s critical.”
The bottom line speaks loudly.
“Hospital care is very expensive,” Ward said. “If someone needs regular visits from a nurse, it’s not difficult if the patient has a home. If a person is homeless, there’s often no good place for them to go that we feel is safe for them to get the care they need, which makes it difficult to discharge them.”
It’s a medically complex population, even more so for older adults, who comprise a growing segment of the homeless. The chronically homeless tend to readmit, thus creating a cycle that drains resources.
Pre-pandemic deliberations among homeless responders noted a medical respite gap.
“Shelters said they need a way to work with the health systems, and health systems said they need a way to work with the shelters,” Doll said. “That really led to the birth of this concept.”
No one could see the problem’s dimensions and solutions until the players started working together.
“We were all seeing it differently from our lenses,” said Kenny McMorris, president and CEO of Charles Drew Health Center.
Organizers studied medical respite models around the country for guidance.
The Wellbeing Partners CEO, Aja Anderson, a public health expert who wrote the grant that funded the program while development director at Charles Drew, applauds this effort to reduce health disparities.
“Medical respite programs are proven to shorten hospital stays, reduce readmissions, improve health outcomes and lower the cost of health care,” she said. “It’s a win for everyone.”
CHI’s Mission and Ministry Fund donated $500,000 to launch the 24-month pilot program, which currently has five dedicated medical respite beds at Siena Francis. There’s capacity for up to 16 beds.
Said Ward, “Now for the first time we have a place for the homeless to go to give them access to whatever they need. They can be seen by their health care provider or by clinical staff who can evaluate them and determine if there’s some treatment they can be given on site where they are sheltered so they don’t have to come back to the hospital. If they don’t have a home, having a place like this is a great resource for them.”
Hospital referrals have been slow as word spreads.
“We have to educate our health systems that this program is available and who’s the appropriate type of patient to refer to it,” Doll said.
“All health care facilities around the city need to be aware of this program,” Ward said, “because my guess is there’s an even greater need for medical respite beds once we all know about it and everyone refers to it.”
Charles Drew President and CEO Kenny McMorris said patients are screened before being discharged, then assisted by a team of case managers and support staff to enroll in health insurance or receive ongoing care.
“After they graduate from medical respite, the whole goal is to teach and support them how to navigate the health care delivery system,” McMorris said.
Siena Francis shelter director Jamise Williams said the program assists participants with their health care and permanent housing needs.
“These people come from an acute care setting. They maybe need to rest a little bit longer, need to have a little more recovery time and have a little more recovery support while also working to find some permanent housing once this respite period is over,” she said.
“Patients are taken by the hand to get where they wish to be so they’re not falling through the cracks,” Williams said.
Williams said they try to provide as much permanent stability as possible, so patients don’t end up returning to homelessness or the ER.
“The goal is to get them into stable housing so we’re not recreating a turnstile of people rotating through the hospital and the emergency department,” said Doll with CyncHealth, which provides technical assistance with Unite Nebraska to track referrals. “They have a better positive healing experience that way.”
Unite Nebraska is a social care referral platform that connects health care and social care.
The homeless population is not monolithic. Just as their demographics and reasons for being without a home vary, service providers represent different touch points that don’t always mesh.
“Homelessness is very nuanced,” Williams said. “There’s so many factors people don’t really understand. Collaboration is definitely a must when trying to fix some of the service gaps and adjust some of the barriers the homeless population faces.”
Sharing information across organizations and disciplines is key.
“That’s exactly what the magic is on this one,” McMorris said. “There’s an intentionality between the health systems. Charles Drew Health Center and Siena Francis House in a very coordinated and deliberate way to address services for those who need post-acute care.”
The homeless also need support after their hospital release that only a focused program can provide.
“All of these individuals have co-morbidities,” McMorris said. “It’s not just hypertension or diabetes. It may be hypertension, diabetes and cardiovascular disease. There’s a high incidence of behavioral health issues. They may be dealing with anxiety or depression. They may also be dealing with a substance-use disorder. The complexity of the population and the health conditions they present is exacerbated by their living conditions. The ability to connect with them is further disputed by their living environment or housing circumstance.”
The program, McMorris said, makes it possible to “be present and stay consistent in the lives of these individuals, which is going to help support them in their journey to stable housing and optimal health.”
A new player in this arena is the City of Omaha, which hired Tamara Dwyer, formerly with MACCH, as its first homeless services coordinator in December.
“We’re excited there’s someone at that level who will be engaged in policy and understanding,” Doll said. “We’re anxious to meet to talk about the work we do and how we can partner. I think whenever there’s elevated attention on an issue and people are talking about it, hopefully more people will be aware.”
“I want to support them how they need it,” Dwyer said of the respite program. “I’m all about collaboration, especially with such a big issue as homelessness with all its complexities.”
In the fluid environment of transient health care, McMorris said, “The team is trying to be as nimble as possible. There’s some guiding principles we operate with, but we’re learning on the fly, and no two patients are alike.”
No one’s expecting miracles.
“Some folks are going to have some lapses, and they’ll end up going back to the emergency room and we’ll be there to catch them and go through the process all over again,” McMorris said.
The program’s informed by social drivers and determinants of health.
Said McMorris, “Health outcomes of an individual are tied to their living environment, the built environment, not necessarily their chronic condition. What’s happening to exacerbate hypertension, diabetes? Could it be inconsistencies in housing? Could it be lack of access to health care? Could it be lack of knowledge on how to navigate the health care delivery system?”
The goal, he said, “is connecting people to all the things that make them healthy and whole and making sure they feel there’s someone to support them. We offer a relationship built on trust and safety. You have to start there first.”
CHI’s Ward is sure the program will make a difference.
“By having this resource available you’re going to have healthier people who have better nutrition and access to health care. You’re absolutely going to decrease the readmission rate and open up beds for those who really need them. I have no doubt this will prevent future unnecessary hospitalizations.”
Intervening early is also essential, Doll said.
“If someone’s coming asking for food or utility assistance we should intervene there because we should be preventing the unhoused situation. Then we need some bridge programs and some pathways to affordable housing. That’s ultimately most important.”
Siena Francis is that bridge.
“Whatever housing and permanent stability looks like for them is what we work towards,” Williams said. “With some we bring up the idea of shared housing. Some might need more support; some might need assisted living, especially if they’re older. If people are not ready to live alone and they have friends and family, we can help them problem solve and reconnect.”
“We’re finding you have to coordinate those things in a very individualized way to meet the needs of the individual. It can’t be a one size fits all in terms of service delivery,” said McMorris.
Local philanthropy supports enough shelter beds and affordable housing units to generally meet chronic or emergency needs, which is why Omaha doesn’t have tent cities. Still, not every need can be met all the time.
“You can always do more,” Ward said. “We always have a need for more mental health and more drug and alcohol rehab.”
Doll sits on a steering committee overseeing the program. She said input from the homeless helped inform it but no one with “the lived experience” of homelessness is in a decision-making role.
McMorris concedes the program is just a start. “We have a long way to go. That’s why we call it a pilot.”
Accountability will be key moving forward.
“When we fall short, admitting that and being willing to fix it together. Being transparent, being honest about what we can accomplish and what we cannot. Then also being able to pivot when something is not going the way we anticipated. There’ll be some things we’ll have to go back and adjust as we figure out how to get them the right care, the right services at that right place and right time.”
Doll’s optimistic the local health and dwelling equation for the homeless is better balanced now than before.
“We’ve become more sophisticated now that care teams are meeting to do more concentrated care coordination around the patients for their appointments and services. It’s certainly evolving and we’re all learning. We’re coming together and leveraging all the assets in our community. I think it’s very empowering and promising.”