Expanding a Medical Respite Pilot for Homeless Individuals in Western New YorkNYHealth awarded Buffalo City Mission a grant to support Western New York’s first medical respite program for homeless individuals in recovery.
Buffalo City Mission
Special Projects Fund
January 2021 – December 2021
People experiencing homelessness have disproportionately high rates of chronic disease, behavioral health challenges, and substance use disorders, yet they face barriers to preventive care and treatment. They often cycle in and out of the hospital and incur high health care costs. Hospitals are financially penalized for not discharging medically cleared patients or for readmitting patients within 30 days of discharge.
As a result, hospitals are often faced with either keeping patients longer than medically necessary or discharging patients back to the streets or to shelters where their health condition worsens, eventually leading to readmissions. Medical respite centers provide a solution for homeless individuals who are eligible to be discharged from the hospital but still require health care services. In addition to transitional housing and medical care, individuals have access to wraparound services—such as medication management, care coordination, and counseling and wellness services—while they recuperate in a safe environment. Buffalo City Mission (BCM) has piloted Western New York’s first medical respite program for homeless individuals in recovery. In 2021, NYHealth awarded BCM a grant to continue piloting its medical respite center, expand operations, and lay the groundwork for replication.
Outcomes and Lessons Learned
Under this grant, BCM:
- Operated the recuperative care unit, which partners with Jericho Road Community Health Center and Spectrum Health and Human Services to provide around-the-clock on-site primary care, behavioral health, and substance use services. Other community partners provided complementary on-site services including legal support, visiting nurse services, diabetes management, housing support, and benefits enrollment for health insurance and SNAP.
- Admitted 52 men experiencing housing instability or homelessness; all of them were assigned a case manager, received a personalized recovery plan, and secured health insurance coverage.
- Convened primary care doctors, care coordinators, visiting nurses, and behavioral health providers for weekly case conferences to manage care plans and support clients’ transition out of the unit.
- Transferred recuperated patients to BCM’s 30-day shelter program and then to its transitional housing program, as appropriate. Residents who transitioned to other housing and needed additional care received it from BCM’s partners, including the Visiting Nurse Association, Meals on Wheels, and mental health and substance use service providers.
- Partnered with the University at Buffalo School of Nursing to assess outcomes during the first year of operations and identify areas for real-time improvement. The assessment found:
- Only 10% of patients have returned to the hospital in the past two years; for those who did return, it was at the request of a physician.
- 84% of patients discharged from the unit remained in care with their primary care physician.
- Secured contracts with three Medicaid managed care organizations, including Highmark Blue Cross Blue Shield, to reimburse for recuperative care unit services.
- Created a set of tools and resources to promote replication and spread of the collaborative model, including:
- a web-based referral form system for local hospitals to assess patients’ eligibility and make referrals;
- a virtual tour of the facility for other social service agencies to assess readiness of their physical plant;
- an assessment tool to gauge patients’ self-efficacy; and
- a grief and loss curriculum for residents.
- Authored a peer-reviewed article on the collaborative medical respite model, submitted for publication in the Journal of Social Distress and Homelessness.
BCM has laid the groundwork to replicate its unique model in Western New York and other regions. It has expanded from a partnership with one area hospital, Erie County Medical Center, to include two additional hospital systems—the Kaleida Health and Catholic Health systems. Partners are also making plans to expand the medical respite recuperative care unit to BCM’s women and children’s shelter, the Cornerstone Manor. BCM and its research partners at Buffalo School of Nursing have also met with a variety of partners to share evaluation findings and present opportunities and strategies for scaling the model. Start-up funding and ongoing reimbursement remains a challenge, but BCM expects to secure at least two additional managed care contracts in the near term. The New York State Department of Health has also signaled interest in investing in medical respite program expansions and is working toward a certification process that could open the door to federal reimbursement for the provision of medical respite services.
Co-Funding and Additional Funds Leveraged: Funding from the Robert Wood Johnson Foundation supported the State University of New York at Buffalo’s School of Nursing team that conducted the project evaluation and developed referral protocols for hospitals discharging patients to the medical respite unit.