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Michael Ferry, LCSW Ada Lopez, MSCED

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

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 Figures provided by Kelly Doran, M.D.
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 Figures provided by Kelly Doran, M.D.
Timing of Readmission 54% within 1 week 75% 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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