Project Name: Homeless Care Coordination Program
Project Overview: Sonoma County, California, home to Santa Rosa Community Health (SRCH), has a high rate of people experiencing homelessness. A recent census count estimated nearly 10,000 homeless persons in the area, many of whom are both chronically homeless and suffering from an array of medical conditions, and who lack an ongoing source of care. Building on an existing model of intensive care management, SRCH aimed to create a patient-centered medical home for high-need individuals experiencing homelessness. The center’s program focused on homeless individuals with chronic conditions and a recent hospital stay or repeated emergency room use, and those referred through collaborating partners. High-touch enabling and supportive services were offered through collaborations with area providers. To expand and strengthen the comprehensive safety net of services, the center worked with area hospitals to leverage data and integrate medical care, social services, behavioral and substance abuse services and social supports.
The goal of the Homeless Care Coordination Program was to improve the health outcomes for vulnerable, chronically ill individuals experiencing homelessness.
Project Objectives were to:
- Create a model for community and medical support of vulnerable homeless persons that improves access across the spectrum of care; and
- Reduce excessive inpatient and ER utilization and hospital readmissions by offering coordination and early intervention, ultimately reducing health care system costs.
- 2015-2016 Key Grant Activities
- Assigned full-time care coordinators to identify high-need, high-risk, homeless patients before they entered the hospital;
- Connected chronically ill homeless individuals with a primary care medical home, assisted patients with SSI and SSDI benefits enrollment, and provided information to assist people in accessing medical services;
- Linked chronically ill homeless individuals to benefits, community supports including shelters, food sources, and transportation, and substance abuse treatment if needed;
- Piloted the use of prepaid cell phones to help patients maintain contact with care providers following discharge from the hospital; and
- Developed a training session for all SRCH care coordinators, focusing on the unique needs of chronically ill homeless persons, emphasizing special services including substance abuse.
- 2015-2016 Key Project Outcomes
- More than 200 individuals were enrolled in the program. These people were offered coordinated medical and social services and engaged in creating self-defined personal care plans. Nearly 90% of the participants were connected to a primary care provider, by the end of the first program year.
- The program shows early evidence of reducing hospital readmissions and unnecessary visits to the emergency room. For the final reporting period, 94% of enrolled patients had no known hospital readmission within 30 days post-discharge, as compared with 70% at the start of the program, and 75% of enrolled patients had no known ER visit within 30 days post-discharge, as compared to a baseline figure of 60%.
- The health center developed and tested data templates to capture care management and care transitions data.
- By establishing strong local partnerships with hospitals, health care organizations and social service organizations, SRCH was able to secure new sources of institutional funding support to continue the program.
- 2016-2017 Key Grant Activities
- Expanded the program beyond health center patients to include all community members experiencing homelessness;
- Integrated a RN care supervisor to coordinate the community care transition programs, consult with care coordinators on medically complex patients, and assist in the development of templates for data capture;
- Developed an acuity scale to identify the needs of participating patients;
- Focused on addressing internal data validity and data capture to improve patient outcomes tracking and reporting;
- Continued to work with area hospitals and community partners to reestablish Care Coordinators Consortium and other mechanisms to enhance timely and reliable information exchange for shared patients; and
- Worked with community partners to address inadequate low-income housing.
2016-2017 Key Project Outcomes:
- During the 9-month project period in 2017, the homeless care coordination program enrolled 135 high-acuity, high-need individuals. Ninety-five were new to the program and tended to be higher acuity, while 40 individuals enrolled in the prior year continued in the program.
- The program successfully reduced hospital readmissions and unnecessary visits to the emergency room. Ninety-two percent (92%) of enrolled patients had no known hospital readmission within 30 days post-discharge, and 74% of enrolled patients had no known ER visit within 30 days post discharge. Seventy-two percent (72%) of newly-enrolled patients had primary care visits within 14 days of enrollment.
- SRCH successfully leveraged collaborations with local, county and multi-county health care and social service organizations to secure additional funding and expand and enhance primary care and mental health services for person experiencing homelessness.
Project partners: St. Joseph Health System (operates Santa Rosa Memorial Hospital in Santa Rosa and Petaluma Valley Hospital in Petaluma), Sutter Santa Rosa Regional Hospital, The Drug Abuse Alternatives Center, Sonoma County Department of Health Services, Partnership HealthPlan of California, Health Care for the Homeless Collaborative, and the Redwood Community Health Coalition.
About the Grantee:
Santa Rosa Community Health provides primary care, mental health and dental services to low-income and uninsured individuals in Sonoma County, CA. SRCH is dedicated to providing excellent patient-centered health care services to underserved people in their community, regardless of their ability to pay. They are dedicated to caring for the whole person with dignity and respect, educating health care professionals, and creating a continuous learning environment for all staff.
Website at www.srhealth.org