Individuals experiencing homelessness can be some of the most challenging patients to treat. Too often they don’t receive they regular care they need, and end up going to the ER only when chronic conditions become acute. Then they are discharged back into a life that makes long term recovery nearly impossible. Central City Concern in Portland, Oregon, has had success in treating this population through their Recuperative Care Program, which uses a medical model for dealing with the complex problems of the homeless.
An Absence of Services
For healthcare organizations seeking to provide vulnerable patients with non-medical care, the traditional approach has been to offer connection to the appropriate social service organizations. But too often there are gaps in these services, or social service organizations don’t have the resoures to serve of everyone in the city who needs help. And these gaps often differ from city to city, making it hard for sweeping state or federal programs to provide a good solution. To fill these gaps, some healthcare organizations have built their own programs, including medical respite programs, to bridge the divide between the hospital doors and a life of real health.
Out of Interdisciplinary Work, A New Approach
Central City Concern (CCC) was founded in 1979 to provide people experiencing homelessness in Portland, Oregon, with a combination of housing and detox services. In the early 2000s CCC began moving into the clinical world. Because of this combined experience in both housing and clinical work, CCC was well positioned to take on a pressing problem in the city. Portland was finding that a few individuals accounted for a disproportionately large part of the city’s health spending. Through an early partnership with CareOregon, CCC moved in 2005 to provide a multi-faceted array of services to these patients experiencing homelessness: housing, case management, and rapid connection to primary care.
Housing After Discharge
CCC’s Recuperative Care Program seeks to catch medically, mentally and behaviorally complex homeless patients when they are discharged from the hospital. Patients are recommended to the program either at discharge or if CCC’s intervention could prevent a future hospitalization. Originally the program started working with a single hospital and a single payer, but has now expanded to take patients from all area hospitals, as well as other diverse entry points, and work with a variety of payers, mostly Coordinated Care Organizations (CCOs).
Patients are given housing in one of the program’s 35 single room occupancy (SRO) units. Taking up almost two floors of an old apartment building, the rooms have a bed, table and chair, and a kitchenette with a stove, fridge and microwave. Before a patient moves in, CCC stocks the room with food, toiletries and kitchen gear. This simplifies many of their patients’ daily struggles, allowing them to focus on their care plan and on transitioning into permanent housing. The average patient stays a little over a month. Though Recuperative Care is definied as a two to six week program, CCC is flexible to longer or shorter stays, depending on the needs and situation of each patient.
Guiding Towards Care—and a Home
Once a patient has moved into their SRO, an on site case management team works with them to help them get in-house primary care, keep their specialist appointments, and develop a plan to find long-term housing. The team also works to help their patients learn or relearn the social and life skills required to stay housed and keep a home. Each morning case workers knock on every patient’s door to deliver juice and a granola bar—an icebreaker that they use as an opportunity to organize the day for their clients, including figuring out how to get them to their medical appointments.
The Recuperative Care Program has a 75% rate of resolving an acute condition that caused a patient to be recommended to CCC. Afterwards 60-70% of patients are placed into some form of transitional or permanent housing—they leave on a trajectory towards stable housing. The remainder are discharged back to the streets, back to the hospital for higher level care, or in a few cases, to jail. 95% of clients leave established with either CCC’s primary care clinic or another primary care provider.
A Hybrid Model
The Recuperative Care Program is a medical respite program, but it also differs from most such efforts in important ways. Medical respite housing is often similar to nursing facilities, with less privacy and fewer private amenities. San Francisco’s medical respite program, for instance, provides dormitory-style housing. CCC’s model emphasises the transformative power of privacy. For many of their patients, the recuperative care SRO is the first private inside space they’ve had for years or decades.
In this way the Recuperative Care Program takes its cues from the “housing first” approach to tackling homelessness. This movement, which is growing in popularity, argues that having housing is itself the foundation of successfully overcoming substance abuse, mental health issues, or chronic illness. Without this foundation, programs that attempt to treat these issues with homeless individuals still living on the street will inevitably struggle to get traction. The Recuperative Care Program incorporates “housing first” principles into the medical respite model to create a community integration program that coaches patients to find success while in supported independent housing.
Similarly, many medical respite programs will kick patients out if they are actively doing drugs. CCC does not, in part because they believe that doing so would leave their patients with no other safety net that can care for them in a cost effective way.
Because of CCC’s limited resources and their limited number of SRO units, the Recuperative Care Program has to constantly make difficult choices to maximize the effectiveness of the program and the value it provides to the Portland community. Unlike hospitals, which usually just keep patients as long as they need to get healthy, CCC must always make room for new patients. This means using a multidisciplinary lens to decide who to keep in the building—they triage based not just on medical acuity, but on whether or not the program is helping an individual make progress. If a patient is not making progress on their health and housing issues, the program may need to invest in another person.
CCC also faces challenges navigating their unique program through a complex regulatory framework. Their program is intended to be inexpensive, but of course they are dealing with a very difficult population. They also have to get potential funders on board, despite structural concerns about mixing healthcare and housing. CCC says much of this work involves advocacy around what trauma-informed care looks like for patients who are experiencing homelessness.
Central City Concern is a 501(c)(3) nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions. Visit their website: www.centralcityconcern.org
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