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Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing
Homelessness and Healthcare: Creating a Safety Net for Super Utilizers  with Medical Bridge Housing
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Chronic homelessness and chronic illness often go hand in hand; individuals struggling with housing insecurity frequently suffer a range of health problems that require hospitalization. Unfortunately, lacking stable housing where they can recuperate renders these newly discharged patients more likely to return to the hospital. 

Recognizing that housing is healthcare, many healthcare organizations, particularly hospitals, now seek ways to address this social determinant of health (SDOH) by identifying housing barriers in their communities and developing initiatives to improve housing availability.

Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing spotlights a California partnership that provides medical 'bridge' housing to homeless patients following hospitalization. This recuperative care initiative reduced avoidable hospital readmissions and ER visits and significantly lowered costs for the collaborating organizations.

In this 22-page resource, Paul Leon, CEO, Illumination Foundation, outlines the Chronic Care Plus Program, a joint venture pilot that began as an ER diversion project and now offers community-based stabilization for medically vulnerable chronically homeless patients. 

Developed by the Illumination Foundation and St. Joseph's Hospital in Orange County, Calif., the pilot resulted in an actual facility that accrued $2.8 million each year in savings over a two-year period.

In Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing, Leon describes the following program elements:

  • The origins of recuperative care or 'medical respite care' for patients that are unstably housed;
  • Profile of 'Joe,' a typical Chronic Care Plus client, and participant criteria;
  • Overcoming the challenges of medical education management in an unstable population;
  • Benefits of retaining clients in the Chronic Care Plus program for as long as possible;
  • Chronic Care Plus assessment of and approaches to SDOH barriers, including financial literacy, job readiness, transportation, mental health connections, and others;
  • Analytics to demonstrate Chronic Care Plus savings from medical avoidance;
  • Importance of addressing behavioral health issues to avoid 'losing' clients back to the community;
  • Steps for moving clients along the care continuum from recuperative care to long-term housing;
  • Lessons learned from the Chronic Care Plus pilot that inform the 'Street2Home' program;
  • and much more.

Table of Contents

  • Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients
    • Profile of a Frequent Hospital User
    • Defining Recuperative Care
    • Recuperative Care Criteria
    • Recuperative Care Program Outcomes
    • Homeless Healthcare Safety Net Model
    • Chronic Care Plus Pilot Program
    • CCP Program Impact
    • CCP Enterprise Analytics
    • Examples of 'Street2Home' Outreach
    • Summary and Lessons Learned
  • Q&A: Ask the Expert
    • Transitioning from Recuperative Care to Long-Term Housing
    • Using EMTs for the High Utilizer Population
    • Savings from Medical Cost Avoidance
    • Comparing Medical Bridge Housing to Recuperative Care
    • Overcoming Barriers from Previous Incarceration
  • Glossary
  • For More Information
  • About the Contributor

This report is part of the HIN Healthcare Case Studies series, which bundles inside details on innovative programs from leading-edge healthcare organizations on a range of topics — all aimed at achieving healthcare's Triple Aim of improving the patient experience of care, improving the health of populations and reducing the per capita cost of healthcare.

If you are already a HIN Healthcare Case Studies subscriber, then this report is FREE for you. Learn how you can save with automatic digital delivery of HIN Healthcare Case Studies.

Publication Date: October 2017
Number of Pages: 22
ISBN 10: 1-943542-70-8 (Print version); 1-943542-71-6 (PDF version)
ISBN 13: 978-1-943542-70-3 (Print version); 978-1-943542-71-0 (PDF version)
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Social Determinants of Health: Using Empathy Interviewing To Help Care Teams Understand Factors Impacting Patient Health, a 45-minute webinar on September 14, 2017, now available for replay
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