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Medical Respite Care: Helping the Homeless Bridge the Gap Between Hospital and Shelter Michael Ferry, LCSW Ada Lopez, MSCED Yale New-Haven HospitalColumbus.

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Presentation on theme: "Medical Respite Care: Helping the Homeless Bridge the Gap Between Hospital and Shelter Michael Ferry, LCSW Ada Lopez, MSCED Yale New-Haven HospitalColumbus."— Presentation transcript:

1 Medical Respite Care: Helping the Homeless Bridge the Gap Between Hospital and Shelter Michael Ferry, LCSW Ada Lopez, MSCED Yale New-Haven HospitalColumbus House 20 York Street586 Ella Grasso Boulevard New Haven, CT 06510New Haven, CT 06519

2 Defining Homelessness:  Homelessness includes those who are  Staying at a shelter  Staying on the streets, outside, or some other place not meant for habituation  Doubled up with friends or family, or temporarily staying in a motel/hotel AND are unable to return or secure alternate arrangements  Includes both chronic and transitional lack of housing

3 Homelessness in New Haven  Homeless in New Haven: 700 people on average  Robert Woods Johnson study by Kelly Doran, MD Statistics from a sample of 113 homeless individuals:  Age (mean): 49 years  Sex: 73% male, 27% female  Insurance: 75% Medicaid  Substance abuse history Figures provided by Kelly Doran, M.D.

4 Entrance to Yale-New Haven Hospital

5 Readmission Rates Of the homeless patients that were hospitalized: 53.8% were readmitted within 30 days Of these readmitted patients:  54% were readmitted within 1 week  75% were readmitted within 2 weeks The collective population of Medicaid patients (which includes the homeless) during this same period had a 30-day readmission rate of 18.7% Figures provided by Kelly Doran, M.D.

6 Timing of Readmission 54% within 1 week75% within 2 weeks Days to Readmission Figures provided by Kelly Doran, M.D.

7 Medical Respite Programs  A literature review found that they:  Improve care delivery and health outcomes  Decrease future Emergency Department visits and inpatient hospitalizations  Decrease length of stay and costs  Allow for the opportunity to connect patients with supportive housing and other services to break the cycle of homelessness Information provided by Kelly Doran, M.D.

8 Description of the Medical Respite Program at Columbus House Shelter  Location: Third floor of Columbus House  Number of Beds: 12  Funding: Pilot grant from the State of Connecticut  Length of stay: Projected to average 21 days, but stays permitted up to 30 days  Referrals: From YNHH inpatient and observation units  Staffing: 24-hour supervisory staff, Visiting nursing for medical care

9 Entrance to Columbus House

10 Learning a Hospital Patient has been Identified as Homeless  Self-disclosure  Consultation by Medical Staff  Review of Documentation:  Address and phone fields  Physician Diagnoses  Nursing Evaluations  Social Work evaluations

11 Eliciting Circumstances of Homelessness “During the past two months, have you been living in reliable housing that you own, rent, or stay in as part of a household?”  If yes, “Are you worried that in the next two months you may not have reliable housing?”  If no, “Where have you lived for most of the past two months?”  “Are you able to return and stay there following discharge?”  If yes, “Are you able to receive a visiting nurse there?”  If no, will this patient have a post-discharge medical need requiring respite?

12 Approaching Discharge  Staff identify an expected post-discharge medical need requiring skilled nursing.  The care manager verifies that the patient meets eligibility criteria for the Respite Program.  The social worker assesses the patient, introduces the idea of Medical Respite, and obtains approval for a Columbus House patient navigator to interview them via a signed release of information.

13 Medical Eligibility for Respite Care  Requires skilled care, such as that provided by a visiting nurse, but not so much as to need a stay in rehab or hospice  Are independent with their ADLs  Transfers & ambulates independently, or using mechanical assistance such as wheelchair, crutches or cane  Are continent of bowel and bladder  Do not require IV hydration. IV treatment is acceptable  Are free from influenza or tuberculosis  Medical issue is reasonably expected to resolve in 30 days or less

14 Psycho-Social Eligibility for Respite Care  Lack suitable housing  Are alert, oriented, and psychiatrically stable enough to receive care and not interrupt the care of others  Are cognitively able and willing to comply with treatment requirements, visiting nurses, shelter case managers, etc.  Are willing to remain substance-free during their stay  If detoxified during their hospital stay, they must be free of symptoms for at least 48 hours  Methadone patients are permitted

15 Medical Respite Care Brochure.

16 Evaluation and Transfer Process  The patient is interviewed by the Patient Navigator  Upon approval for Medical Respite, the care manager submits referrals to a local medical clinic (or other designated medical provider) and a home nursing agency.  A detailed discharge checklist is used to minimize complications afterward  Upon discharge, Columbus House staff escorts the patient from the hospital to the shelter.

17 Typical Concerns Before/After Discharge  Patients are sometimes discharged without all necessary prescriptions/wound care/diabetic supplies  Patients may not have active prescription coverage with which to fill or refill their prescriptions  Prior medications being continued may not be verified as within the possession of the patient  The patient may not not have the resources to secure non-covered or over-the-counter medications  The new and/or ongoing medications may not being prescribed in sufficient quantity to last until the patient’s next appointment  Patients are sometimes discharged without a named doctor, occasionally only a clinic, and sometimes only a follow-up appointment with a specialist  Prescriptions for Medical Respite patients are sometimes sent to pharmacies other than our Apothecary, sometimes creating delivery/procurement issues  Patients are sometimes discharged without established medical appointments, and are instead being told to make their own appointments  The patient’s primary care physician sometimes cannot be contacted, or is unwilling to prescribe prior to an initial appointment

18 Discharge Checklist

19 Respite Patient’s Room

20 Continued Care  Weekly Case Review meetings which include  Social workers, case managers, and pharmacy from Yale-New Haven Hospital,  Staff from the Medical Respite Care program, and  Staff from local clinics and home nursing agencies Patient care, safety, and transitions to additional services are discussed  Ongoing exchange and tracking of information regarding the identification, progress, and outcome of patients.  Ongoing steering committee meetings address systemic issues impacting the program and patient care

21 Preliminary Data From October 7 to April 30:  493 patients were identified as homeless and screened (includes repeat patients)  The above screenings resulted in 321 unique patients

22 Average Age = 48.6 Years

23 Sex

24 Race

25 Preliminary Insurance Numbers… (Includes repeat patients)  Covered by Medicaid = 83.4%  Covered by Medicare = 15.8%  Covered by private insurance = 1.8%  No insurance = 9.9%  Patients with Medicare or Husky C and thus are either aged or disabled = 37.5%

26 Preliminary Mental Health and Substance Abuse Numbers…  Patients assigned a mental health diagnosis, even if not currently experiencing symptoms = 62.0%  Patients abusing alcohol: 53.6%  Patients using illicit drugs: 54.8%  Combining the alcohol & drug numbers, 77.6% of patients were actively abusing alcohol or using illicit drugs, while 22.4% were not misusing either.

27 Preliminary Medical Numbers: (Includes repeat patients)  Patients without a Primary Care Provider upon admission = 37.9%  Average number of Emergency Department visits during the prior 365 days = 14.2  Most common presenting issue = Alcohol Intoxication/Withdrawal (17.9%)  Runner-up presenting issue = Chest Pain (10.5%)  Most common chronic condition = Diabetes (16.4%)  Average number of medications prescribed at discharge = 6.7

28 Preliminary Disposition Numbers… Out of 474 discharges (includes repeat patients):  50 patients were admitted to Medical Respite (10.5%)  32 patients went to a skilled nursing facility (because their needs were more than could be managed at Respite) (6.8%)  93 patients had family or friends willing to take them in (19.6%)  155 patients went to standard shelter services, due to not meeting criteria (typically due to lack of a medical need requiring recuperation) (32.7%)  61 patients declined respite or shelter services choosing the street instead (12.9%)  37 patients identified as homeless had a residence or acquired housing at discharge (7.8%)  38 patients went on to other forms of care, e.g. inpatient psychiatric or substance abuse treatment (8.0%)  8 patients could not be included, e.g. due to rapid discharge or demise (1.7%)

29 Initial Impact  Average number of Emergency Department visits during the prior 365 days = 14.2, for all screenings  12 of 26 Medical Respite patients (46%) who completed the program returned to the Emergency Department at least once following discharge from the program  8 of 26 patients (31%) that completed the Medical Respite program returned to the hospital within next 30 days  Annualized rate of Emergency Department visits following discharge from Medical Respite = 7.7 visits  Excluding our most unusual outlier patient, the annualized rate of Emergency Department visits following discharge from Medical Respite = 4.6

30 Recommendations  Comprehensive training regarding the program and identification/referral of homeless patients  Thorough assessment of patient ability and motivation for self- care/medical compliance  Marketing materials for patients unfamiliar with or reluctant to return to the shelter  Comprehensive treatment plan prior to discharge, with special attention to insurance and medications  Ongoing and open channels of communication re:  Readmissions  Progress/obstacles  Safety issues  Weekly multi-disciplinary team case review and planning meetings  Thorough investment and cooperation from home nursing agencies  Medical review of challenging/recurring cases  Ongoing data collection


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