Program takes homeless patients from "revolving door" to recovery

Each year, hundreds of people who are homeless are admitted to Yale New Haven Hospital – many with chronic medical conditions such as diabetes, heart disease and psychiatric illness.

"In the past, when those patients were discharged, many had nowhere to go, let alone access to necessary follow-up care," said Paula Crombie, LCSW, director of Social Work, YNHH. "Often, they ended up back at the hospital – in some cases, multiple times."

A 2012 study of 113 patients who were homeless showed that within 30 days after discharge, over 70 percent returned to the Emergency Department and over 50 percent were readmitted for inpatient care.

To better assist these patients, YNHH joined with Columbus House, which provides shelter, housing and services for people experiencing homelessness, and other community partners. With state support, they created a Medical Respite Program to provide care, housing and other services for people discharged from the hospital who have no home to go to.

Through the program, which opened at Columbus House in October 2013, YNHH staff interview patients to identify those eligible for the program.

Hospital social workers and care managers then work with Columbus House staff to arrange post-hospital care at the Respite program. Upon participants' arrival, Respite staff create medical and housing service plans for them, connect them with primary care providers, arrange transportation to medical appointments and refer participants to behavioral health and employment services.

On Feb. 23, Medical Respite Program staff and task force members joined with hospital, community and state leaders to celebrate the success of a program that has taken 206 homeless individuals from the "revolving door" of repeat hospital visits and put them on the road to better health. Among program participants, the 30-day hospital readmission rate dropped from 50.8 percent in 2012 to 16.7 percent in fiscal year 2016. The average length of stay dropped from 10.6 days in fiscal year 2015 to 7.1 days in 2016. Task force members said greater collaboration among YNHH and community care providers, increased staffing and resources, intensive case management and housing for participants contributed to the program's success.

"Ensuring that patients experiencing homelessness have an appropriate place to go with the care they need immediately after discharge is crucial to their healing," said Michael Ferry, LCSW, senior clinical social worker, YNHH. "Helping them find permanent housing, medical care, employment and other services helps keep them healthy."