Highland Hospital created a respite center at a local homeless shelter where recently discharged homeless patients could recover.
Homeless patients have a very chaotic experience after leaving the hospital. They have nowhere to convalesce, no way to get prescriptions and nowhere to put them, and no way for the hospital to contact them to see how they’re doing. They’re forced to start thinking about their basic survival rather than their recovery, so their readmission rates are very high. The hospital can put them up in a hotel for 2-3 nights, but then what? We needed somewhere for them to go where they could focus on getting well and just have the time to reflect on their health.
Highland Hospital is a non-profit teaching hospital in Oakland, CA. It is a safety net setting hospital with 236 beds that serves a diverse population including low-income, uninsured, and vulnerable populations. Their transitions program began in 2012 and is influenced by Project RED and the Transitional Care Model.
What We Tried
We worked with a local homeless shelter to create a respite center for our homeless patients who were being discharged to “home.” It’s a room in their shelter that can hold 10 men. The residents can stay there 24/7, instead of having to leave during the day like the rest of the shelter. They get 3 meals a day plus an onsite nurse to take care of them. They stay in the respite center for 2-6 weeks before transitioning to the permanent shelter or to a new home. In that time, our transitions team provides medical case management and education while a case manager from the shelter helps them with life coaching, getting an ID, finding a home, etc.
This is a really great part of our program and we’re working to expand it now. So far, 54 men have gone through the respite center and their readmission rate is 7% (lower than the general readmission rate at the hospital). What’s more, 28% have moved on to permanent housing and others have moved into sober living houses. Having patients at the center also enables us to conduct 10 home visits at one time, where before we couldn’t even reach these patients.
We’ve learned so much about homelessness through our conversations with the patients and the case managers at the shelter. We never had the ability to work with homeless patients for extended periods of time. This has really helped us tailor our program to better meet their needs.
We facilitate group learning and wellness coaching for all the people in the respite shelter and that has proved to be very valuable. There can be 10 people living in a small room together all day every day. It’s important that they learn to get along together and that there be some constructive enjoyable activities.
We screen our patients to make sure no one has uncontrolled and untreated mental illness and there are no sex offenders or arsonists. These are rules of the shelter, but also make sense for our respite center since these patients will be confined with others in a tight space for 2-6 weeks.