1. Care Alliance Recuperative Care (CARC) Care Alliance Health Center 2100 Lakeside Men’s Shelter

2. Care Alliance Recuperative Care (CARC) Respite care through the back door 3-Tiered System Shelter-based/Motel-based Daily nurse visits Coordination with other community health care services Follow-up beyond discharge to continue the process of linkage with community resources

3. CARC Tiers Tier 1-Daily nurse visits in shelter, no 24 hour bed Tier 2-Daily nurse visits in shelter, 24 hour bed Tier 3-Regular nurse visits in motel, motel voucher

4. Case Example 1 Patient EC 53 year old male Wrist fracture and puncture wounds to both shins Identified in shelter cafeteria

5. Case Example 1 Patient identified by another shelter resident Patient’s primary concern was wrist fracture Upon examination, puncture wounds in shins were discovered

6. Case Example 1

7. Patient initially treated in public ED Provided temporary cast, prescription for Percocet and recommendation to follow up with orthopedics the next business day Leg wounds had been bandaged with gauze

8. Case Example 1 CARC team identified and admitted individual to Tier 2 Patient was provided 24 hour access to a bed and daily nurse monitoring with physician appointments every two days Patient given tetanus shot and started on antibiotics Follow-up appointment with orthopedics department was facilitated

9. Case Example 1 Shortly after admission, infection in puncture wounds was noticed and patient taken to public hospital Patient admitted to hospital for 7 days with MRSA/osteomyelitis Patient was discharged to skilled nursing facility for continued antibiotic treatment

10. Case Example 1-Outcomes Earlier and more aggressive management of wound infection Facilitated continued therapy for wrist fracture Advocated with hospital on behalf of patient Social reintegration Reestablished connections to family

11. Case Example 2 Patient RL admitted to CARC Tier 3 following assault Patient discharged from hospital with broken jaw and appointment for surgery to repair jaw Patient received regular (every 2-3 days) nurse visits and support in preparing for surgery

12. CARC Strengths & Limitations + Flexible to meet needs of patient Mobile to continue patient advocacy Holistic approach considers social, psychological, and material goals as well as medical goals - Limited therapy options Still a general shelter environment Limited staffing

13. CARC future goals Establish designated space in shelter or other facility Expand staffing to enable more regular care Include volunteers in supporting the recovery of CARC patients

14. CARC partnerships First phase of long road of future development to improved capacity Partnership Goals  Formalize partnership relationships for health care services  Establish outside funding sources  Strengthen our relationship to our parent organization locally and other respite providers nationally Capacity Service Partnerships Funding/Political Partnerships HCH Base Respite Care Providers Network

15. CARC partnerships Service Partnerships  Shelters  Hospitals  Skilled Nursing Facilities  Volunteers Funding/Political Partnerships  County Office of Homeless Services  Local Foundations  Hospitals

16. CARC Partnerships Lessons It always takes longer than you think it should Everybody has a unique interpretation of the problem and a unique set of solutions and a unique set of pressures There will be times when you think everybody is finally on the same page and then....

17. CARC Partnerships Lessons Baby steps to recuperative care, baby steps to recuperative care Be clear about problem definition before moving on to proposed solutions; write it down Be patient and persistent

18. CARC Partnerships Lessons Do not ignore what you are already doing, or should be doing for your patients. Do it well. Document it. Be precise in your goals and accomplishments during evaluation. Promising what you did not deliver will not be a step forward.

19. Final thought Remember that it is about providing the quality of care that these patients deserve