Medical Respite – Santa Clara

The Santa Clara County Medical Respite Program (MRP) is a collaborative program between the Hospital Council of Northern & Central California (and the eight participating hospitals in the county it represents), a local shelter provider (EHC Lifebuilders), and the Valley Homeless Healthcare Program (VHHP) which operates the program on a day-to-day basis. The planning for the MRP was coordinated by the Hospital Council during a county-wide initiative to end homelessness that was initiated by Don Gage, member of the Santa Clara County Board of Supervisors, and San Jose Mayor, Chuck Reid.  The participating hospitals are Stanford Medical Center, Regional Medical Center, Santa Clara Valley Medical Center, El Camino Hospital, Palo Alto VA Hospital, Kaiser Santa Clara, and Kaiser San Jose.

The program provides 15 beds for homeless patients who are being discharged from participating hospitals. These beds provide a clean, safe place for the patients to recuperate and continue with self-care rather than trying to recuperate on the streets.  They have served over 215 homeless patients during their first 2 years in operation.

In addition to helping the patient recover from their acute hospitalization, the MRP is trying to break the cycle of the homelessness. The homeless individuals’ lack of a clean, safe, healthy living environment and lack of a medical home leads to acute and chronic health care conditions that cannot be adequately treated. It has been shown across the country that Medical Respite programs shorten the length of the hospital stay for homeless patients, and decrease readmission to the hospital and Emergency Department. The patient’s stay in the MRP also provides an opportunity for making linkages to other services, including permanent housing, while the individual is in the MRP.

The EHC LifeBuilders’ shelter on Little Orchard is the site for the MRP where optimal space is available for semi-private patient rooms and support space. Staff for the MRP is funded through VHHP’s current Federal Healthcare for the Homeless grant and an expansion specifically for the Respite Program. This funding pays for the following staff: registered nurse, social worker, psychologist, and medical director. These staff are available Monday through Friday from 8:00 to 5:00. The MRP space is also conveniently located next to the VHHP clinic that operates at that site.  Respite patients are referred to the VHHP clinic for primary care, and referral to SCVMC for on-going care and treatment.

Hospitals in the County estimate that 50-55 homeless patients are discharged each month that could benefit from transfer to a Medical Respite Program. The average length of stay in the Medical Respite Program is 30 days, with a range of 2 days to 90 days. The program serves homeless adults with acute medical conditions who are medically stable,  independent in activities of daily living, and able to care for themselves. For example, the Medical Respite Program provides services for homeless patients recovering from infections or surgeries who, if they had stable housing, would be discharged to their homes with necessary supplies. The Medical Respite Program is serving approximately 130 homeless patients each year.

The desired outcomes of the program are:

  • Provision of a clean, safe place for recuperation
  • Decrease in the return to the emergency room and/or readmission to the hospital after discharge
  • Medical home assignment (if patient does not have one) and facilitation of on-going care, including specialty care, to provide continuity in management of acute and chronic conditions
  • Facilitation of treatment for psychiatric diagnosis and referrals for on-going psychiatric care when needed
  • Completed applications for entitled benefits (SSI, MediCal, GA, etc) when the patient does not already receive them
  • Completed applications for permanent housing, including subsidies when applicable
  • Temporary housing at time of discharge if permanent housing applications still in progre
  • Provision of intensive case management services for on-going support when appropriate

These outcomes are achievable because medical homes are provided through our partner, VHHP, for patients who do not have a medical home, including access to specialty care during the patient’s respite stay and after. Patients who have no healthcare insurance are entered into a healthcare coverage plan, such as MediCal and the County Health Plan. Patients are also assisted in applying for all the benefits they are entitled to, including Food Stamps, General Assistance (GA) and SSI. In addition they are assisted in locating housing and housing subsidies if eligible.  If permanent housing is not available at time of discharge, temporary housing is found while waiting for permanent housing.

Staff in the MRP conducts comprehensive health and psychosocial assessments of referred patients.  These assessments are the basis for individualized plans and services that link the homeless patients to ongoing, comprehensive primary care in their medical homes, specialty care, supportive housing, entitled benefits, substance abuse and mental health treatment, and other needed supports and services.  These interventions are needed for the homeless patient to achieve improved health outcomes, an increase in quality of life, and ultimately maximum functional status.

Staff in the adjacent VHHP clinic provide the following to patients in the program in their on-site clinic:

  • Regular physician and/or nurse visits
  • Medications and medication management
  • Self care planning and education
  • Health education and patient support groups
  • On going primary and preventive care
  • Chronic disease monitoring and management
  • Psychiatric consultation and mental health services
  • Transportation to specialty care appointments
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