Care Transitions for the Homeless

July 23, 2014

Hosted by the RARE Operating Partners:

Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health

Our host’s today will be…

Kathy Cummings, RN, BSN, MAProject Manager, ICSI

Jill Kemper, MAProject Manager, ICSI

Webinar Objectives

• 1. To learn about programs and resources focused on care transitions for the homeless.

• 2. To understand the challenges in working on care transitions for the homeless.

• 3. To learn about opportunities to connect with others working on care transitions for the homeless in Minnesota.

Why RARE Conversations?

Networking opportunities

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Learn

Conversation Engage

July’s Conversation…

Care Transitions for the Homeless

Sharing their work:Minnesota Department of Human Services, Catholic Charities, Guild

Incorporated and Hearth Connection

More about the presenters…

Julie Grothe Kelby GrovenderDawn Petroskas

John Petroskas

Kristine Davis

Building the case for medical respite care for

homeless adultsJohn Petroskas

Minnesota Department of Human ServicesJohn.Petroskas@state.mn.us

What is Medical Respite Care?

“Medical respite care is acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to be in a hospital.” National Healthcare for the Homeless Council

Lots of respite info and a short video:http://www.nhchc.org/resources/clinical/medical-respite/

Medical respite is valuable

• Respite programs are an important part of the homeless service continuum.

• Respite care is an effective intervention, offering recovery from illness or injury as well as connections to housing, primary health care, disability benefits, treatment, and supportive services.

• Medical respite programs are cost effective.

Respite Planning Process

January 2003: MESH convenes 1st community provider mtg.June 2003: One-day needs survey is conductedMarch 2004: Minneapolis Foundation planning grantSeptember 2004: Hennepin County Healthcare for the Homeless Project receives Medica Foundation startup fundsEarly 2005: 20-bed respite program for homeless men begins at Salvation Army Harbor Light shelterToday: respite program continues to serve homeless patients suffering from acute illness or injury

Community Provider Meetings

• Monthly meetings for nearly two years• Staff from more than 20 agencies participated:

shelters, hospitals, clinics, outreach programs, drop-in centers, and metro counties.

• We sought to develop a respite service model that would meet the needs of homeless people in the Twin Cities.

Needs Survey

• Conducted on a single day (June 16, 2003)• Simple one-page survey instrument• 65 sites agreed to participate• Objective: learn how many acutely ill or

injured single homeless adults would benefit from temporary respite shelter, if available.

Survey Results

• 77 surveys returned• 35 most-likely respite candidates identified• 70% men, 30% women• Average age: 42 (range 18-63)• Most were insured• Most frequent sites of medical care were

HCMC (46%) and Regions (11%)

Survey Results

• Most common conditions: post-surgical recovery, orthopedic injuries, pneumonia, burns, cellulitis, back injuries, renal failure, ear/nose/throat illnesses

• Most common needs: rest (60%), medication management (30%), dressing changes (20%), care coordination (14%)

• Most needed only brief period of respite care

Wilder Homelessness Survey

• Added question to 2003 statewide survey• 24.7% of those who visited an ER in the last six

months said they had been released with instructions they couldn’t follow because of their homelessness

• 8.7% of all homeless adults surveyed

Transitional Recuperative Care

Dawn Petroskas, RN, PhDDirector of Health

ServicesCatholic Charities of

St. Paul and Minneapolis

July 23, 2014

Transitional Recuperative Care Pilot

• January 1, 2012 to January 1, 2013 • Funded by Medica Foundation and North Memorial

• Provide safe and dignified space for homeless people being discharged from the hospital to recover from acute illness/injury or stabilize from an exacerbation of a chronic condition.

Pilot Goals

• Improve patient health outcomes

• Promote patient’s human right to health and dignity

• Decrease recidivism

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04/20/23 19

Estimated Avoidable Health Care Costs

20

Exodus Health Supported Housing/TRC

819 2nd Ave. S Minneapolis

• Patients range from 25 to 82 years old - 60% are over 50

• Over 30% come with equipment needs (e.g. oxygen, catheters, walkers, colostomy, laryngeal device)

• Mental Illness – 50% Chemical Dependency – 40%

• 46% are people of color • Patients are referred from:

Hennepin County Health Care for the Homeless (30%)Hennepin County Medical Center (20%)Hennepin Health (18%)North Memorial Health Care  (17%)Mental Health Facilities (6%)Shelters (4.5%)Community (4.5%)

04/20/23 23

Who We Serve

•Respite Care: Effects on the Perceived Health & Health Care Utilization of Homeless Adults

– University of MN - Center for Health Equity in Clinical and Translational Science Institute

•Medical Respite Care for People Experiencing Homelessness

– National Health Care for the Homeless Council

04/20/23 24

Research & Evaluation

Thank You!

dawn.petroskas@cctwincities.org651-647-3127

Hospital to Home: Alternative Interventions Leading

to Stable Housing & Reduced Use of Emergency Departments

Not-for-profit, accredited community mental health provider with roots in the early 1970’s

Exists to help people with mental illness lead quality lives

Service Lines: In 2013 the agency served over 2,300 individuals across all service lines.

Community Treatment Assertive Community Treatment, Mobile Integrated Case

Management and Care Coordination Teams Residential Services / Supportive Housing

Intensive Residential Treatment Crisis Stabilization

Delancey Services Specialized, intensive, mobile team services for people

experiencing chronic homelessness compounded by mental illness, substance abuse, trauma & violence

Supported Employment Services

About Guild

Project Partners

Project Partners agreed to answer the following questions as a way to address costs as well as service provisions:

Can a hospital identify its highest cost patients who also have long histories of homelessness?

Can a health care system and a supportive housing organization partner to create an intervention that links care management and supportive housing?

Would such an intervention lead to better care and reductions in hospital admissions, length of stay and emergency department visits?

Is there a way to re-invest savings into supportive housing interventions for this population?

Key Questions

Project Premise

A disproportionate amount of hospital emergency department and inpatient resources are used by small group of people.

H2H takes an innovative and collaborative approach to assist individuals experiencing: Homelessness Mental illness Substance use disorders Chronic health conditions 

Goals: Decrease avoidable healthcare usage Improve housing stability Increase use of primary care clinics and

primary pharmacies Increase client self reliance and life

functioning

Project Goals

Persons must meet the following criteria to be considered for participation

Have long histories of homelessness – 4 times in the past 3 years or 1 year continuous

Frequent users of Emergency Departments – at least 5 visits in the past 12 months

Eligibility Requirements

Have one or more of the following chronic medical conditions COPD/asthma Diabetes Renal failure Congestive heart failure/coronary artery disease Cancer HIV/AIDS

Possibly have mental health issues

Eligibility Requirements

Outreach and engagement—building relationships Housing—providing safe affordable homes with use

of housing subsidies Person-centered and strengths based—tailor

services to the person’s needs and preferences Focus on the “practical” Tenacity essential—”Carry the hope” for recovery

Intervention Strategies

Mental health services—provide med assistance and linkage to psychiatric services

Substance abuse services—use harm reduction and motivational interviewing

Integration of services and treatment—include assistance with employment

Comprehensive care coordination and health promotion—link and collaborate with primary care, behavioral health, pharmacies, social services

Intervention Strategies

Guidelines and mutual agreements for partners:

Care Coordination Effective communication is key to providing optimal care.

Care Transitions Communicate clearly and directly to improve transitions of

care. Give and accept respectful feedback when agreements

and expectations are not met.

Care Coordination Guide

Participant Communication Maximize self-management of health conditions

through person-centered care. Assure meaningful participation by participants in

development of treatment and care. Support participant to build and involve natural

support networks. Celebrate accomplishments.

Care Coordination Guide

Housing Participants may pay up to 30% of their income for

housing Rental assistance pays the balance

Primarily HUD Supportive Housing Program funds Community Health Services Team

Average monthly cost of services $1,100 per participant Primarily Medical Assistance, HUD SHP, and state

funding through LTHSF

What does it cost?

Data sharing agreement with Minnesota Department of Human Services, Regions Hospital and Guild Incorporated

Guild contracted with Wilder Research to evaluate the project

Evaluation and Data Sharing

Evaluation addresses four questions:1. Who are the Hospital to Home clients?

2. How has participation in Hospital to Home affected client healthcare usage over time?

3. How has participation in Hospital to Home affected client housing stability over time?

4. How has participation in Hospital to Home affected client life functioning over time?

Evaluation and Data Sharing

Please see the handouts: Hospital to Home Expansion Factsheet, February

2014 Hospital to Home Outcome Survey, November

2012

For more information about Hospital to Home outcomes, see the series of reports by Wilder Research from June 2011 to present

http://www.wilder.org/Wilder-Research/Publications/Pages/results-Homelessness-Housing.aspx

Outcomes

Future webinars…

To suggest future webinar topics contact:

•Kathy Cummings,kcummings@icsi.org

•Jill Kemper, jkemper@icsi.org