Peaks Region care sites address needs of unhoused patients, reduce length of stay

Catholic Outreach Day Center_11 2022

As part of our commitment to the communities we serve, Intermountain Health is addressing the most critical needs of our patients in the Peaks Region, with emphasis on those who are poor and vulnerable. When several of our care sites began noticing increased numbers of homeless patients coming to the Emergency Departments multiple times for care, the teams knew they had to do something to help.   

Historically, people experiencing homelessness have been harder to serve because it’s difficult to locate and communicate with them post-discharge to encourage their healthy recovery and connect them with the needed post-acute care and resources. These patients also have a higher likelihood of cycling through emergency services due to their resource challenges. 

To combat this, Saint Joseph, St. Mary’s and Lutheran hospitals partner with cross-functional, multi-agency groups that are skilled at working with the homeless population. Through this collaboration, they’re able to connect patients with temporary housing, which ultimately leads to better outcomes, reduced length of stay and reduced readmission rates. 

The teams work with Regional Accountable Entities (RAEs), which are care coordination agencies that work on behalf of Medicaid. They are responsible for coordinating members’ care and ensuring they are connected with primary and behavioral health care. 

“By collaborating with RAEs, our care sites can get a care plan set up for patients experiencing homelessness who often have high readmission rates,” said Alison Keesler, manager of Value-Based Programs. “Ultimately, we’re able to place patients in temporary housing and long-term care facilities. The RAEs we work with include community-based organizations that do navigation work and behavioral health work for hard-to-reach populations.” 

This work is part of Intermountain’s value-based care model and the Hospital Transformation Program (HTP). As part of the HTP, Colorado hospitals must select 10 cost and quality performance metrics based on their community health needs assessments. Readmission rates are one of the metrics the Peaks Region is focused on, so they looked at what populations are readmitting the most; people experiencing homelessness were at the top of the list. 

“We screen for social determinants of health and send positive screens to the RAEs,” Alison said. “We identify barriers that patients have to healthy recovery, whether it's transportation or people being too busy worrying about their housing to address their healthcare needs. We then help get them connected with housing.” 

Transitional care managers, also called navigators, work with patients post-discharge to ensure they have what they need, are in a safe place, keeping up with their medications, and more. 

At St. Mary's, doctors from the Family Residency Program provide free medical care to people experiencing homelessness through a partnership with Grand Valley Catholic Outreach Day Center. Each week they provide patients with basic medical care, preventative healthcare and counseling services at no cost. They also work with those experiencing addiction issues and help set them up with primary care physicians. This partnership with the Center provides the patients with a safe and comfortable place with a home-like feel where they’re much more likely to come in when issues first arise instead of waiting until they’re really sick and have to go to the Emergency Department. 

At Lutheran, they have a two-fold effort to help patients experiencing homelessness. They offer a collaborative working space to Jefferson County homeless navigators on the Lutheran campus that allows the navigators to come together and talk about what they're finding and what their needs are.  After discovering that transitional housing often entails an empty unit with no furniture, the Lutheran team also donated 20 rolling, foldable beds to the Jefferson County program to give to patients so they will have a bed to sleep in.  

They also purchased six medical respite beds through an organization called Recovery Works. When a person experiencing homelessness comes to Lutheran and is treated, oftentimes it requires care at home afterward. Historically, these patients would stay in the hospital for weeks or months, but now Lutheran can discharge them in a normal timeframe to go to Recovery Works. They stay there for 35 days and have their own room, meals, a nurse checking on them, counseling, substance use disorder treatment, and a navigator who connects them with housing. 

“These things probably wouldn't happen if they were to stay in the hospital because we don’t have the internal resources or ability to provide that type of much-needed care,” said Chuck Ault, Community Health program manager at Lutheran. “By discharging them to Recovery Works, they have people checking in on them constantly and there are substance use groups several times a day for them to go to. It gives them the chance to be part of a group experiencing the same issues. We’ve seen great success – patients have been discharged from there to sober living communities and temporary and permanent housing. This collaboration means we get to do the right thing for these vulnerable patients to help improve their lives.” 

These models exemplify our commitment to whole-person care, promoting improved health outcomes by ensuring patients’ social, emotional, psychological and environmental needs are met.