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, MA
Project Manager, ICSI
Jill Kemper, MA
Project 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
Why RARE Conversations?
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
Dawn Petroskas
John Petroskas
Kelby Grovender
Building the case for
medical respite care for
homeless adults
John Petroskas
Minnesota Department of Human Services
[email protected]
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:
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 conducted
March 2004: Minneapolis Foundation planning grant
September 2004: Hennepin County Healthcare for the
Homeless Project receives Medica Foundation startup funds
Early 2005: 20-bed respite program for homeless men
begins at Salvation Army Harbor Light shelter
Today: 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, PhD
Director of Health Services
Catholic 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
Transitional Recuperative Care Patient Usage of
Hospital-Based Services
(14 Patients)
Year Prior to TRC
Year Following TRC
ER Visits
Hospital Admissions
Estimated Avoidable Health Care Costs
Exodus Health Supported
819 2nd Ave. S Minneapolis
Who We Serve
• Patients range from 25 to 82 years old - 60% are over
• 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%)
Research & Evaluation
• Respite Care: Effects on the Perceived
Health & Health Care Utilization of Homeless
– University of MN - Center for Health Equity in Clinical
and Translational Science Institute
• Medical Respite Care for People Experiencing
– National Health Care for the Homeless Council
Thank You!
[email protected]
Hospital to Home:
Alternative Interventions Leading
to Stable Housing & Reduced
Use of Emergency Departments
About Guild
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
Project Partners
Key Questions
 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?
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:
Mental illness
Substance use disorders
Chronic health conditions
Project Goals
 Goals:
 Decrease avoidable healthcare usage
 Improve housing stability
 Increase use of primary care clinics and
primary pharmacies
 Increase client self reliance and life
Eligibility Requirements
 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
Renal failure
Congestive heart failure/coronary artery disease
 Possibly have mental health issues
Intervention Strategies
 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
Care Coordination Guide
 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
 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.
What does it cost?
 Housing
 Participants may pay up to 30% of their income for
 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
Evaluation and
Data Sharing
 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?
 Please see the handouts:
 Hospital to Home Expansion Factsheet, February
 Hospital to Home Outcome Survey, November
 For more information about Hospital to Home
outcomes, see the series of reports by Wilder
Research from June 2011 to present
Future webinars…
To suggest future webinar topics contact:
• Kathy Cummings,[email protected]
• Jill Kemper, [email protected]