1. Reducing Hospital Utilization in the Context of Housing Uncertainty and Multiple Conditions Brian Akers, BS Psychology; Audrey Hendricks, BA Anthropology Health Coaches, Camden Coalition of Healthcare Providers Patient Background  48-year-old Hispanic Male  Bilingual in Spanish and English  $1,100 per month in SSD  Strong family support  Medicare and Medicaid recipient  Homeless/unstable housing situation  Admissions for urosepsis, knee pain, fever, hypotension  Congenital Liver Disease  Diabetes Mellitus Type II  Depression/Anxiety  Osteoarthritis  Limited mobility since bilateral knee replacement in 2010 Utilization and Cost Outcome  Reduced utilization: 1 ED visit since intervention  Patient empowered to manage medical follow-up independently  Improved quality of life: At graduation patient stated he was “feeling in the sky” compared to how he felt at the start of the intervention. System Failures  Communication failures between medical and social service providers  Poor infrastructure for transfer and maintenance of medical records  Lack of provider accountability  Waste of patients’ and advocates’ limited time, energy, and resources  How can patients expect to advocate for themselves and navigate a system that experienced social workers and health professionals struggle to? Medical History  2 inpatient, 0 ED visits in the 6 months prior to intervention  1 ED visit during 2 month intervention, 1 ED in the 3 months post intervention *Based on estimated total hospital receipts Medical Intervention Scheduling assistance and accompaniment to physician appointments Medication education and reconciliation Physical therapy enrollment Diabetes self management education Reinforced relationship with primary care Social Intervention Denoted a Power of Attorney Drafted a Living Will Obtained new Medicare card Settled outstanding medical bills Utilities assistance Coaching on how to access and benefit from the various health resources available Housing Transfer Patient was temporarily living with ex-wife and daughters at start of intervention Housing voucher obtained through CPAC Emergency funding assisted with first month’s rent and security deposit Administrative setbacks prevented voucher funding from being released Patient’s housing situation remains unresolved. He has applied for a new voucher through VoA and is currently relying on CFS funding on a month by month basis Graduation Intervention Acknowledgments: Jason Turi (RN), Elisa Perin (RN), Hilda Mateo (LPN), Jeneen Skinner (LPN), Jessica Cordero (MA), Bill Nice (SW), Ana Johnson (SW), Kelly Craig (SW), Audrey Hendricks (HC), Carolyn Junior (HC), Katharine Royer (HC), Brian Akers (HC) Partner organizations: Bayada, Loving Care, Collaborative Support Programs of New Jersey, Community Planning and Advocacy Council, Camden County Department of Community Development, Center for Family Services, Ferry Landing Apartments (Conifer Village), Volunteers of America, Hispanic Family Center