Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness JULY 2021 AUTHORS Jill Donnelly, Jessica Layton, and Lucy Pagel, Aurrera Health Group Contents About the Authors 3Introduction Jill Donnelly, MPH, Jessica Layton, MPH, 5 Project Background and Lucy Pagel, MPH, are consultants with Aurrera Health Group, a mission-driven 5Findings health policy and communications firm based Promising Practices in Sacramento, California. 9Challenges Acknowledgments The authors would like to thank all the medi- 10 What's Next? cal respite programs that participated in the 11 Case Studies interview and survey process for their time and candor. While there is a great deal of vari- 13 Appendices ation among the programs, it is clear that a A. Survey of Medical Respite Landscape in California mission-driven passion for serving the home- B. California Medical Respite Programs – Program Detail less population is a constant across the state. C. Glossary Many thanks as well to Julia Dobbins for lend- ing her support and expertise on this project. 24 Endnotes Design by Dana Kay Herrick; cover illustra- tion by Jamiel Law. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measur- able improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. California Health Care Foundation www.chcf.org 2 "A lot of the folks we serve who are homeless - they don't want and/or need a lot. Sometimes they just want to be left alone. Sometimes they don't need expensive medical services. What they are looking for is connection and family and community. Our recuperative care program keeps people out of the hospital, and it's cost effective and that's great. What it really does is allows people to feel at home and comfortable. Recuperative care has allowed us to serve the folks that previously hospitals would have sent out to the street, or to skilled nursing or other institutional settings. It is a very human decision to try to find other ways to support people to live their lives with some autonomy. For many homeless folks, that is all they have left - what they choose to do with their bodies and where they are placed. I am hoping we can continue to foster and grow this out, because it is a benefit to the community." - Isaias Acosta, Hospitality House Recuperative Care Program Introduction M edical respite programs are unlicensed orga- As California drives toward implementation of the nizations that provide acute and post-acute California Advancing and Innovating Medi-Cal care for individuals experiencing home- (CalAIM) initiative,1 which aims to coordinate care for lessness who have recently been discharged from Medi-Cal recipients, who currently experience some the inpatient setting. The programs are a growing of the most fragmented care, an opportunity exists part of the homeless services continuum throughout to leverage promising practices and grow statewide California. This paper surveys the California medical capacity in medical respite. However, to succeed, such respite landscape and examines the variation in pro- programs will need new billing and reporting functions grams by program components, funding sources and and contracting arrangements with local managed mechanisms, and associated challenges. care plans or centralized contracting entities. Medical respite programs vary by type. Some have a National. Medical respite programs in the United largely medical model of care, while others strive to States emerged in the 1980s. Today, approximately integrate a combined medical-social model. A few 100 respite programs exist across 29 states. Medical have yet to integrate clinical care, despite the pressing respite, also known as recuperative care, provides need. Where possible, most programs form partner- acute and post-acute care for individuals experiencing ships with local health centers, hospitals, homeless homelessness who are too ill or frail to recover from a service providers, and other entities to address the physical illness or injury on the streets but are not ill health of the whole person, including their physical, enough to require a hospital or skilled nursing facil- mental, spiritual, and social needs. These partnerships ity (SNF) level of care. These programs typically offer drive referrals and can facilitate continued care after short-term residential care that allows clients to recu- discharge from medical respite. Many programs braid perate in a safe environment, with access to medical together funding streams from hospital community care and other supportive services. Medical respite benefit dollars, county funds, and, increasingly, man- can be offered in a variety of settings, including free- aged care plans. standing facilities, homeless shelters, nursing homes, and transitional housing facilities.2 In 2016, a task force Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 3 of medical respite experts for the National Health Care CalAIM initiative. Under ILOS, Medi-Cal managed for the Homeless Council (NHCHC) released the fol- care plans (MCPs) in every county can opt to contract lowing standards (PDF)3 for medical respite programs: with medical respite providers and fund the care pro- vided using Medicaid dollars in lieu of more expensive $ Standard 1. Medical respite program provides hospital or nursing facility care. While this option does safe and quality accommodations not make medical respite a full Medi-Cal benefit, it will $ Standard 2. Medical respite program provides greatly expand the Medicaid funding available for this quality environmental services type of care across the state. Historically, California hospitals have been major funders of medical respite $ Standard 3. Medical respite program manages services, funding beds through direct staffing and timely and safe care transitions to medical community benefit dollars and grants. While ILOS respite from acute care, specialty care, and/or may increase the quantity of medical respite services community settings funded through Medi-Cal managed care, hospital $ Standard 4. Medical respite program adminis- funding will likely continue to be a core source of pro- ters high quality post-acute clinical care gram financing. $ Standard 5. Medical respite program assists in health care coordination and provides wrap- around support services CalAIM Initiative ILOS $ Standard 6. Medical respite program facilitates The CalAIM initiative includes ILOS that MCPs can choose to provide. These services are provided in safe and appropriate care transitions from lieu of higher-cost services traditionally covered by medical respite to the community Medicaid. Proposed by the Department of Health Care Services (DHCS), the following list includes the $ Standard 7. Medical respite care is driven by current 14 ILOS: quality improvement $ Housing transition navigation services Even with these medical respite standards established, $ Housing deposits it is unclear how many programs have adopted the $ Housing tenancy and sustaining services standards in practice. Only a small number of the pro- $ Short-term post-hospitalization housing grams interviewed were aware of the NHCHC medical $ Recuperative care (medical respite) respite standards, and none of those programs cited $ Respite services these standards in conversation. $ Day habilitation programs $ Nursing facility transition/diversion to assisted California. The number of medical respite programs living facilities, such as residential care facilities has increased over the past several years, as both for elderly (RCFE) and adult residential facilities public and private funders have invested in expand- (ARF) ing provider capacity to meet a growing need. $ Community transition services/nursing facility Beginning in 2015, Medi-Cal seeded and supported transition to a home several medical respite pilots under California's Whole $ Personal care and homemaker services Person Care program, authorized under California's $ Environmental accessibility adaptations Section 1115(a) Medicaid waiver, Medi-Cal 2020. (home modifications) Several county-led pilots chose to invest in medical $ Meals/medically tailored meals respite services and infrastructure. Building on those $ Sobering centers learnings, in January 2022, the Department of Health $ Asthma remediation Care Services (DHCS) will launch medical respite as an In Lieu of Services (ILOS) (PDF)4 alternative under the California Health Care Foundation www.chcf.org 4 Value. Research on the value of medical respite a payer's perspective, AHG added interviews with programs demonstrates significant cost savings, Los Angeles County's Housing for Health program, improved health outcomes, and improved hous- Dignity Health, L.A. Care Health Plan, and National ing outcomes.5 Medical respite programs have been Health Foundation. shown to shorten hospital stays6 and decrease read- missions by discharging clients to lower levels of care instead of to the street. Findings A 2009 study of Boston Medical Center's medical The process revealed significant variation statewide in respite program found that discharge from a hospi- medical respite program design, scope, and funding tal to a medical respite program was associated with (see Appendix B for a detailed list of programs) approximately a 50% reduction in the odds of read- mission at 90 days post-discharge.7 Another study Model of care and staffing. Thirteen of the 20 published in Journal of Health Care for the Poor and responding programs identified as a combined medi- Underserved found that a day spent in the hospital cal-social model of care, three programs identified as is nearly 10 times more expensive than a day spent a social model of care, and three others identified as a in medical respite. Clients who receive respite care clinical or medical model of care. spend an average of two fewer days in the hospital, and their future emergency visits decrease by 1.8 Medical model. Programs following a medical days.8 Further, the Illumination Foundation found that, model usually employ medical staff, including medi- in addition to cost savings, 92% of individuals who cal doctors, physician assistants, registered nurses, received medical respite experienced an increase in and licensed vocational nurses. These programs are income. Seventy-four percent secured supplemental focused more on providing required medical services security income (SSI).9 and less on providing social services. Most of the med- ical programs are able to provide some on-site care, including post-acute and primary care, nursing care, medication reconciliation, disease management, and Project Background mental health services. These programs often have In collaboration with the California Health Care RNs or LVNs who conduct assessments and facilitate Foundation (CHCF), Aurrera Health Group (AHG) safe discharges from medical respite. conducted a six-month survey and interview pro- cess to capture the current landscape of medical Medical-social model. The combined medical and respite. AHG surveyed 40 service providers, received social model is typically staffed with RNs, LVNs, and responses from 20 programs, and conducted follow- other clinicians who provide direct medical support up interviews with 11 programs. Through both the as well as on-site care management services. These survey and interview processes, programs provided programs work in partnership with local hospitals details on their program models, clinical processes, and Federally Qualified Health Centers (FQHCs) to external partnerships, funding, challenges, and prepa- provide robust medical services. The medical-social ration for upcoming policy changes (see Appendix A model offers the same on-site care and services as for a detailed breakdown of these programs). Partway the medical model, with added social services to help through the interview process, it became clear that clients connect with programs and benefits for after sustained funding, referral pathways, and funder discharge. Several medical-social models also include requirements were common challenges for medical community health workers (CHWs) and social workers respite programs. To better inform these challenges or other behavioral health staff. and understand the benefits and constraints from Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 5 Social model. Programs with a social model employ Referrals. The majority of medical respite programs few clinical staff members. Several programs include identified their primary referral source as local hospi- licensed clinical social workers (LCSWs), case man- tals, many of which have a direct funding relationship agers, and CHWs on their teams, but these staff with the medical respite program. Other common members are not able to provide direct medical care. referral sources include shelters, health plans, home- These programs are primarily located in smaller com- less services agencies, and less commonly, street health munities with fewer resources. Because the nonclinical programs, and mental health and SUD programs. programs are unable to provide medical services, they must send clients back to the hospital should a In Los Angeles County, the county-run Housing for medical issue arise. While the social model programs Health program is a primary referral source for many described a strong need and desire to incorporate medical respite programs. Referral processing can be more clinical services to better serve clients, these labor intensive; many programs noted the need to programs face barriers of insufficient funding and staff. bring on additional staff to support the high volumes Notably, programs that are not able to provide high of referrals. quality post-acute care may not meet all the standards outlined by the NHCHC unless they are able to estab- Exits to the community. Every program described lish clinical partnerships. the difficulty of connecting discharging clients to permanent supportive housing (PSH) or long-term Other staffing considerations. On-site staffing cov- transitional housing. The majority of programs - some erage varies widely across programs. While some of which are able to provide services for only 10 to 14 programs provide around-the-clock client support, days - discharge many clients to shelter beds. For many struggle to fund and find coverage for nights some, colocation and partnership with a local shelter and weekends. The Illumination Foundation, which provides an opportunity for coordinated discharges. operates throughout Southern California, offers round- the-clock medical staff. In their interview, they noted All medical respite programs interviewed included that this staffing model helps them reduce emergency housing navigation services in their service model, room visits after hours and on the weekends. though the service intensity varied widely. Most pro- grams have a pipeline to multiple housing options, Many programs expressed the need to have more including Section 8 vouchers, PSH, and tempo- in-house mental health and substance use disorder rary supportive housing. Several programs have (SUD) staff. Six of the responding programs reported found success in using the Homeless Management having on-site mental health professionals; only three Information System, a community-based and client- of the responding programs employ SUD profes- level database, to collect and share information on sionals. In several organizations, behavioral health their clients. Many providers conduct a Vulnerability professionals are available only part-time. Santa Index - Service Prioritization Decision Assistance Tool Clara County Medical Respite Program is unique as part of their standard practice and connect clients in its ability to offer a full-time psychologist funded to the Coordinated Entry System (CES) whenever pos- through a Stanford community benefit grant. More sible. For example, San Francisco Medical Respite than 90% of the clients seen in the program have and Sobering Center has an on-site case manager some degree of undiagnosed or untreated mental who helps navigate CES and ensures that every client health disorder. This capability is not common, how- receives a housing assessment. ever: Harder+Company's 2020 study of Los Angeles (funded by UniHealth Foundation) found that only In most cases, medical respite stays are intended to 43% of medical respite programs in the county can provide short-term residential care to clients recov- accept clients with behavioral health concerns such as ering from an inpatient stay. California's limited severe mental illness.10 affordable and subsidized housing inventory makes it California Health Care Foundation www.chcf.org 6 difficult for medical respite programs to identify tem- to community health and help provide linkages porary and permanent supportive housing options for to programs that address social determinants of clients at discharge. The exception to regions experi- health. To qualify for community benefit dollar use, encing this pervasive challenge is Los Angeles County, the nonprofit hospital must conduct a community where some programs have been able to leverage needs assessment to justify the funds and must Measure H funds to serve clients for up to two years. submit a yearly plan identifying the programs that will be receiving the funds.11 The majority of medi- Partnerships. Several programs found clinical and cal respite programs identified hospital community programmatic support through a partnership with benefit dollars as a primary source of funding for a local FQHC or hospital. Collaboration and even their services. These dollars are often more flexible colocation of the two entities allowed for better coor- than other types of per diem financing models and dination of primary care and social service needs. can be used to finance both clinical and nonclinical For some programs, FQHC partnerships led not only staff. to better health outcomes for clients but also to the development of a strong referral source. $ Hospital per diem payments. Many hospitals have programs that fund beds for short-term stays In Alameda County, LifeLong Medical Care, a local in medical respite, typically 10 to 14 days. An FQHC, operates a medical respite program under extended stay, which is often needed, requires contract with Alameda County Health Care for the additional approvals. Homeless (ACHCH). The medical respite program collaborates with Alameda Health System, a county $ Grants. A few programs have secured short-term safety-net health care system, 14 ACHCH-funded grants, usually on an annual basis. Grant funding street medicine teams, and LifeLong's Trust Health is reportedly difficult to obtain and not a sustain- Center to identify people in need of medical respite able funding source. Interviewees described some and to coordinate referrals. grants as too narrowly prescriptive, making it difficult for programs to invest in long-term infra- At Santa Clara County Medical Respite, the team uses structure needs, such as electronic health records the model of the Valley Homeless Healthcare Program (EHR) or leasing property. to promote the medical model of care across all local homeless service providers, including medical respite. $ Whole Person Care (WPC) pilots. Several county Unlike many medical respite programs that directly WPC lead entities provide medical respite funding employ clinical staff, most of the members of the through their WPC pilots, initially launched in 2016. clinical team are employees of the county. The team Of the 20 medical respite programs surveyed in provides interdisciplinary care by coordinating closely September 2020, 10 cited WPC pilots as a funding with their hospital colleagues and other local entities. source. While the initial five years of WPC funding has been extended for a sixth year through the end Funding. Because medical respite is not a Medi-Cal of 2021, the funding will not be renewed beyond benefit and not typically covered by other sources of that time. The state's goal is to transition all exist- health insurance, the funding landscape is diverse and ing WPC clients who are eligible for Enhanced Care unstable. Programs are funded through four primary Management (ECM) and ILOS to the new programs sources: in January 2022. However, because medical respite is an optional ILOS, it is not guaranteed that the $ Community benefit dollars. The Affordable Care service will be offered by the MCP, so funding to Act allows nonprofit hospitals to utilize community programs that rely on WPC dollars may be lost. In benefit dollars to cover medical respite care. These Placer County, WPC funding allowed the Gathering funds are intended to strengthen connections Inn to open a second recuperative care program. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 7 The WPC pilot partnered with the Gathering Inn to Inland Empire region - must adhere to each region's provide case management and other wraparound medical respite program requirements. In Los Angeles services to WPC medical respite clients. County, the Illumination Foundation is funded through Measure H and the DHS, and the program must meet $ Measure H. Through a quarter-cent tax increase in the guidelines and specific reporting requirements 2016, Los Angeles County's Measure H has created in the county. In Orange County, they are supported a stable and reliable funding source for a variety of by the county and the local MCP, both of which have homeless services. Measure H funds are allocated their own guidelines and reporting requirements. In annually based on the regional percentage of peo- the Inland Empire region, the Illumination Foundation ple who are homeless in Los Angeles County, and submits claims directly to the local MCP. funds are administered by lead county agencies, such as the Department of Health Services (DHS) and Evaluation. Most interviewees discussed the lack of Los Angeles Homeless Services Authority (LAHSA). access to client information and outcomes, such as The goal of Measure H is to combat homelessness diagnostic and claims data, needed to conduct robust through a variety of programs, including bridge pro- evaluations of their program's impacts; this informa- grams such as medical respite, case management, tion is typically housed with local MCPs and hospital and subsidized and affordable housing.12 Both systems. Because many are stand-alone programs, the Illumination Foundation and the Recuperative they typically do not have standing data-sharing Care Center at the Martin Luther King, Jr. Medical agreements with these institutions. Santa Barbara's Campus noted that Measure H funds allow them to Cottage Recuperative Care Program is an exception; extend the stay for clients who have ongoing medi- through their partnership with the county and their cal needs, until they can be transitioned to housing. local MCP, they are able to track client utilization and Notably, the MLK Recuperative Care Center has health outcomes over time using managed care and an unusually long length of stay, ranging from six hospital data sources. This analysis has proven use- months to two years, partly because of Measure H ful for both program administrative purposes and funding. for demonstrating cost savings and improved health outcomes to funders. In Contra Costa County, the $ Medi-Cal health plans. While not a widespread Philip Dorn Respite Center can access their clients' practice, several Medi-Cal health plans have begun EHR data through a partnership with the county's funding medical respite programs. Some utilize WPC program, but they are unable to access the community benefit dollars, others reserve beds on financial data that would allow them to measure the an ongoing basis, and still others pay a per diem cost savings associated with medical respite care. A rate to supplement a longer stay than hospitals wide range of evaluation measures are used across will allow. The National Health Foundation has programs, depending on the level of data access and established partnerships with several hospitals and analytic capacity. Included in the list are the following health plans to fund reserved beds on an ongoing measures: basis or to pay per diem to support the plan's eli- $ 30-day,90-day, and 6-month hospital gible members. readmissions The need to braid multiple funding streams has $ Inpatient psychiatric readmissions also led programs to tailor their lengths of stay and $ Client satisfaction eligibility criteria to the payer, creating complex admin- istrative workstreams. For example, the Illumination $ Discharge site Foundation, a large medical respite program that $ Emergency department utilization manages 200 beds across three different geographic areas - Los Angeles County, Orange County, and the $ Inpatient utilization California Health Care Foundation www.chcf.org 8 $ Chronic conditions encounters to MCPs. This requirement may prove especially challenging for programs that do not have $ Length of stay an established relationship with their local MCPs and $ Bed days for those that do not have clinical staff with a National Provider Identifier to bill for services. As a solution to $ CES assessment this problem, the Illumination Foundation has estab- $ Connection to primary care lished a medical group that is now providing primary care services to this population. While this option is $ Cost savings not available to most programs, it demonstrates the innovation occurring on the ground. Smaller programs Promising Practices may require different yet equally innovative billing During the interview process, a number of promising solutions in the years to come. practices were identified as essential to the success of the program: Coordination with local partners. Acutely ill indi- viduals experiencing homelessness interface with the $ 24/7 on-site staff health care and social services systems at multiple $ Medical and social service staffing points, making essential the need for coordination among entities. Yet many barriers remain around $ On-site behavioral health staff data sharing and care coordination as medical respite $ FQHC and hospital partnerships, colocation programs try to manage relationships with hospitals, with clinical services health plans, county behavioral health organizations, FQHCs, and homeless service providers. $ Data exchange with health plan or public hospital system Sustainable funding sources. For many programs, $ Connection to CES annual budgets vary widely from year to year, depend- ing upon grant acquisition, community benefit dollars, and county funding resources. Funding instability leads to challenges in meeting the community need, Challenges attracting and retaining staff, and growing program Even as medical respite programs advance innova- capacity. tions and promising practices, they face significant challenges. Exits to the community. Many programs discussed the challenge of securing permanent supportive Standardization. While there is a clear need for varia- housing options for discharging clients. The lack of tion to meet local needs, many interviewees voiced housing options often drives up the length of stay in concern at the lack of standardized expectations medical respite. In addition, the discharge process can from various funders. Programs described the admin- be resource intensive and require coordination with istrative burden of when funders differed in their many other entities to ensure that clients have the requirements around eligibility, referral processing, appropriate medication, care planning, and services length of stay, rates, reporting, billing, and program- arranged for a successful transition back into the com- matic elements. This inconsistency may also lead to munity. While some programs have been able to hire challenges as MCPs attempt to set standard contracts discharge planners, many have struggled to identify and requirements under ILOS. funding streams for these roles. Billing. As an ILOS service provider, medical respite Gaps in the continuum of care. Most programs programs will be required to submit claims or noted the challenge of meeting the needs of clients Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 9 with acute or complex medical needs who do not currently licensed or accredited; MCPs will be tasked meet criteria for placement in an SNF. For example, with establishing the minimum required service level Providence St. Joseph's CARE Network medical for ILOS contracting. Though not required, MCPs respite program noted that they are unable to accom- will need to collaborate to establish standardized modate clients who require assistance with personal expectations of medical respite programs, particularly care or administer medication in their program, but within a given county, so as to avoid provider admin- these clients are often not accepted into SNF care istrative overload. Medical respite programs will also locally. Additionally, programs discussed the chal- need support in navigating managed care, including lenge of providing services such as wound care and contracting, credentialing or vetting processes, bill- assistance with activities of daily living because of not ing requirements, reporting, prior authorizations, new having the appropriate staffing, facilities, or funding referral processes, and program compliance elements. to fill the need. Programs with a close connection to Programs that contract with multiple MCPs may have a local hospital system or FQHC are better able to to navigate varying eligibility criteria, lengths of stay, fill this gap, helping clients avoid emergency room reporting, and other administrative requirements. visits and readmissions through strong primary care. It is recommended that the state establish provider- Another gap occurs for clients who need palliative focused learning communities that provide the care or end-of-life care, including hospice services. hands-on, specialized support required to make the Clients admitted to medical respite with advanced shift into managed care. illness often do not wish to be moved to a new facil- ity for end-of-life care, but programs struggle to fund Counties may continue to play a significant role in the higher service level and extended lengths of stay supporting medical respite programs as independent these clients require. Some programs are striving to funders, referral coordinators, and potential adminis- meet this need. In Humboldt County, St. Joseph's can trative and contractual hubs. refer clients to a hospice house, but the cost is often too great at $500 per night. While hospice and pallia- In an environment of increasingly sustainable funding, tive care services are covered by Medi-Cal, medical medical respite programs may have the opportunity respite programs face many barriers, including licens- to grow in capacity, partnerships, and program model. ing requirements, costs, and the space needed to The integration of medical respite with managed care offer hospice or palliative care. may also allow medical respite programs to develop new relationships and improve coordination with local providers, facilitating care and exits to the community. What's Next? Community benefit. An opportunity exists to expand CalAIM. Assuming that the ECM/ILOS plan outlined upon the success of hospital community benefit pro- in the CalAIM proposal is approved by CMS, begin- grams by increasing the size of existing programs and ning in 2022, MCPs will have the opportunity to cover building new programs. With a clear value statement the costs of medical respite services under the ILOS and the growing statewide network, hospitals may see program. While a few MCPs are already funding these improved outcomes and returns on investment. services in various ways, the ability to opt in to ILOS represents a significant shift in medical respite funding Evaluation. There is a distinct need to establish an and oversight. To ensure the success of this new type evaluation framework for medical respite programs, of contractual partnership, MCPs will need support in particularly for those participating in the CalAIM pro- understanding the value of medical respite programs, gram. Creating and adopting a statewide or national metrics of success, and the existing network across the set of evaluation standards will assist in ensuring equal state. Medical respite programs in California are not access to high-quality medical respite services. California Health Care Foundation www.chcf.org 10 Case Studies may come with California Advancing and Innovating Medi-Cal's implementation may offer opportunities to further expand services. Providence St. Joseph Hospital Medical Respite Program Cottage Recuperative Care Program HUMBOLDT COUNTY SANTA BARBARA COUNTY The CARE Network program is part of Providence St. Led by Cottage Health in Santa Barbara County, the Joseph Hospital, which is a nonprofit, Catholic hos- Cottage Recuperative Care Program is a 10-bed pro- pital in rural Humboldt County. The program uses gram co-located within PATH, a local shelter. The funds from Care for the Poor, a community benefit average length of stay at Cottage Recuperative Care program, to partially cover the costs of the medical is 77 days. The program is staffed by both a full-time respite beds and the staff who are provided through and a part-time registered nurse. In addition to pro- a partnership with the Betty Kwan Chinn Homeless viding medical care, a community health navigator Foundation. The foundation provides 24 onsite non- provides case management support, connecting cli- clinical staff and CARE Network provides a registered ents to housing and social support services. Cottage nurse and a social worker to support the discharge. Health also runs a shorter-term care program that The program has a total of 14 beds across three differ- serves as a landing place for potential recuperative ent locations – 10 at Betty's House, operated by Betty care clients being assessed to ensure they are a good Kwan Chinn, three in a clean and sober living house, fit for recuperative care. Referrals come through Santa and one motel room that is usually reserved for those Barbara Cottage Hospital, as well as from community with mental health issues or for couples. The average organizations and government agencies. Cottage length of stay at St. Joseph's is 21 to 30 days. Because Health supports the program through community the CARE Network team is part of the hospital staff, benefit dollars. Other funding is provided by CenCal team members bring with them expertise to navigate Health Plan, UniHealth Foundation, and other private a complex system. Access to basic medical records, funders. including recent medical history, and access to infor- mation on chronic health conditions, has been key to Cottage Recuperative Care has the rare ability to helping clients transition from a hospital stay to the access electronic health records (EHR) data to evalu- medical respite program. ate its services. Access to the Cottage EHR system, Epic, has allowed the program to chart progress notes The St. Joseph program leadership supports including while a client is in their care, track client outcomes, and hospice or palliative care in the medical respite center understand the hospital's return on investment. Their but has been unable to do so due to the lack of staff, standard tracking includes a 90-day pre-medical and licensing restrictions, costs, and availability of space. post-medical respite program view of emergency room and inpatient service usage, which has shown a 45% to The rural nature of Humboldt County limits the num- 65% decrease in emergency room and inpatient utili- ber of inpatient hospice and skilled nursing facility zation 90 days following discharge. Tracking this data (SNF) beds in the area, and home-based hospice is has aided in encouraging hospitals to join conversa- not an option for clients experiencing homelessness. tions about the benefit of medical respite services. Including these services in the respite program would be valuable to the community. When local SNF beds The main challenge Cottage Recuperative Care are unavailable for qualifying clients, St. Joseph's Program faces is the lack of post-respite housing often must look to nearby counties to seek out other options. Cottage Recuperative Care is looking to part- options for the clients. ner with a community organization on establishing housing and wrap-around services for medical respite St. Joseph's current model is supported by local com- clients who face limited options due to housing short- munity benefit dollars. The changes in funding that ages and the cost of housing in Santa Barbara County. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 11 Martin Luther King Jr, Medical Campus Recuperative Care Center LOS ANGELES MLK Recuperative Care Center is a shelter-based program with 94 beds and two hospice beds. The program is funded through the allocation of Measure H funds administered by Los Angeles County Department of Health Services' Housing for Health. MLK Recuperative Care is a medical-social model program that employs medical providers, nurse practi- tioners and registered nurses; medical assistants; and nonclinical social support staff, such as case workers, social workers, and plainclothes security. Clients are referred to the program through Housing for Health and county hospitals. The length of stay in the MLK program is atypically long, varying from six months to two years. MLK's length of stay sits at the nexus of medical respite and interim housing and represents an innovation that communities may wish to explore for their highest-risk and most acute clients. Many clients are moved into transitional or permanent supportive housing (PSH) when they are discharged. To help sup- port long-term success for those who transition out of the program, MLK offers educational classes, such as budget planning and household needs. The program invites "graduated" clients back for Thanksgiving, Christmas, and other holidays, especially if the client has no family within close proximity. The MLK Recuperative Care program shared chal- lenges related to the housing crisis in Los Angeles. While the goal of Measure H is to increase access to housing, it is not always easy or ideal to keep clients in the program until transitional housing or PSH becomes available. At times, it is also challenging to transition clients back to independent living because they have become accustomed to living in the program's facili- ties and being a part of MLK's community. To assist with this transition, MLK offers clients the opportunity to alternate spending nights in a new housing environ- ment and at the medical respite facility until they are more comfortable living on their own. California Health Care Foundation www.chcf.org 12 Appendix A. Survey of Medical Respite Landscape in California Aurrera Health Group (AHG) conducted a six-month survey and interview process to capture the current landscape of medical respite in California. AHG surveyed 40 service providers, received responses from 20 programs, and conducted follow-up interviews with 11 programs. Programs provided details on their program models, clinical processes, external partnerships, funding sources, and services provided. Programs were allowed to select more than one option. A selection of "other" allowed programs to add free text detail to their response. Figure A1. Organization Type "Other" responses included: $ Federally Qualified Health Center (FQHC) NUMBER OF PROGRAMS Homeless services community-based organization $ Nonprofit FQHC 7 $ Combined service facility County homeless services $ Recuperative care services program 3 $ Recuperative care services for homeless population Other community-based organization $ Recuperative care 3 $ Community-based organization focused on County health department serving underresourced communities 2 $ Homeless recuperative care for patients being Health system discharged from hospitals, skilled nursing facilities 2 (SNF), etc. $ FQHC collaboration with shelter-based services Other (please describe) 13 $ County whole person care $ Partnership with heath system and homeless Note: All 20 programs responded. service organization Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 13 Figure A2. Program Funding Sources "Other" responses included: $ VeteransHealth Administration contracts, AB 109 NUMBER OF PROGRAMS Hospital funding Counseling Services contracts, local hospitals, Federally Qualified Health Centers (FQHCs), 10 county hospital Whole Person Care funding $ LosAngeles County Department of Health 10 Services – Housing for Health program Local government support $ Private company 7 $ Private pay FQHC partnership 5 Health plan funding 4 Medicaid 3 Private/philanthropic grants 3 Private donations 2 Continuum of Care 1 HUD 1 Other (please specify) 5 Notes: All 20 programs responded. HUD is US Department of Housing and Urban Development. California Health Care Foundation www.chcf.org 14 Figure A3. Clinical Services Provided Onsite "Other" responses included: $ All services are provided via home health or NUMBER OF PROGRAMS Medication management mobile physician, along with secured storage of medications, mobile psych, and assign staff to 15 escort clients to medical appointments when Nursing care client is in need of higher level of assistance (e.g., mobility issues, visual impairment). 14 $ Cognitive testing, therapy Disease management $ Exam room is next to the recuperative area 12 managed by Federally Qualified Health Center Post-acute medical care (FQHC). Occupational therapy / physical therapy 12 visiting nurses are ordered through the hospital or primary care physician. Medications can be Primary care delivered or picked up by clinical staff. Med box 10 fill is available. $ Non-24-hour nursing care, nurse assessment daily Mental health services no direct nursing care such as wound care 10 $ Nursecare under a clinic setting (immunizations, Acute medical care wound care, line care, EKG, nebulizer, etc.) 7 $ We are partnered with a federally funded community clinic, who has office/clinic space Substance use disorder treatment within our facility. 5 Other (please specify) 6 Note: Nineteen of the 20 programs responded. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 15 Figure A4. Admission Criteria "Other" responses included: $ CalOptima member and acute medical condition NUMBER OF PROGRAMS Currently homeless $ Domestic violence or arson history are not 19 accepted. No active infectious disease. We have a community alternative site for COVID-19 positive. Adult No active drug use, but outreach can offer a treat- 19 ment program if interested. Ambulatory $ Ifbriefs/diapers are used, independent with 17 changing of briefs/diapers must be met. $ No EF, no MRSA, no TB, no C. diff Can administer own medications $ No more than a one-person assist 16 $ Others not marked are allowed, case by case Continent 13 $ Scabies, lice, C. diff, bedbound $ Terminal cancer Does not require IV fluids 12 $ We take those with serious mental illness who we believe can still manage in a group environment Does not have severe mental illness and care for themselves, practice a harm reduction 7 model. $ Willingto participate in the program, willing to No family members adhere to shelter's Good Neighbor Policy 6 Does not have certain health conditions/diseases 5 Does not require oxygen therapy 5 Not actively using substances 5 No history of violence 4 No criminal background 2 Other (please describe) 10 Note: All 20 programs responded. California Health Care Foundation www.chcf.org 16 Figure A5. Referral Sources "Other" responses included: $ All referrals come from Los Angeles County NUMBER OF PROGRAMS Hospital, inpatient Department of Health Services - Housing for Health program (DHS HFH) 16 $ Any community organization or agency Hospital, emergency department $ DHS HFH 15 $ Nursing homes, City Net Homeless service agency CMs or SWs $ Occasionally medical staff from the FQHC with 13 speak to the patient at the hospital. Outreach Hospital, outpatient worker will also speak to the patient about treat- 13 ment options for substance use disorder if the patient is interested. (COVID-19 has made contact Health Care for the Homeless Program a little more complicated.) 9 $ Some patients can be physically evaluated as needed. Shelter 7 $ We seldom do bedside evaluations in the hospital, only if there is uncertainty if client is appropriate. Outreach For outpatient referrals, we often do a "meet and 6 greet" to ensure program mutually acceptable for client and staff. Seldom take referrals from county Jail/prison jail, but have collaborated on a few occasions. 5 Mental health and substance use programs 5 Transitional program 5 Self-referred 2 Other (please specify) 7 Note: Eighteen of the 20 programs responded. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 17 Figure A6. Onsite Accommodations "Other" responses included: $ Case management NUMBER OF PROGRAMS Shared rooms $ Do not distribute medication; coordination 20 between primary care provider and pharmacy services, designated smoking area, outdoor Lounge area courtyard 18 $ Do not distribute medication; provider secure Dining area storage and access 17 $ Laundry room: free; transportation van: free Storage area for belongings $ Outdoor space 17 $ Personallockers for medications. Med box assistance as needed. Lyft or staff transportation. Private counseling space Three meals a day are provided. Kitchen access 14 suspended due to pandemic at this time. Clinical examination rooms $ Private room for clinical calls 12 $ Provide assistance with filling pillboxes. Will store and administer meds on rare occasions Medication management (e.g., withdrawal management). 11 $ Semi-private rooms, semi-private restrooms Kitchen access 7 Private rooms 4 Cell phones 3 Accommodations for family members 1 Other (please specify) 9 Note: All 20 programs responded. California Health Care Foundation www.chcf.org 18 Figure A7. Social/Support Services Provided "Referral to other community resources" responses included: NUMBER OF PROGRAMS Housing navigation $ Assist with SSI, GSR, DMV, birth certificates 20 $ Assistance with becoming document-ready for housing and addressing any social needs the Transportation patient sets as goals 20 $ Birth certificates, drug court, much more Assistance with benefits (i.e., SSI) $ CBEST, Legal Aide, Public Counsel, ACESS, DPSS, 19 Social Security, DMH, Veterans Programs Assistance connecting to medical insurance $ Facilitate transportation, primarily through Veyo 19 and public transportation; substance use disorder counseling; behavioral health services; TeleCare; Access to food programs shelters; back-to-work programs; medical supply 18 services (e.g., wheelchairs, canes, diapers) $ Legal aide, share housing program, counseling Health education through Petaluma Family Therapy, substance use 18 disorder support, case management Referral to other community resources $ Mental health, substance use referrals 17 $ Outreach and engagement, low income assisted living facilities, room and boards, Grandmas House Appointment accompaniment of Hope, Adult Protective Services, ALW Program 16 $ Outside appointments Workforce development $ Specialty medical and dental referrals 4 $ SSI, DMV, DPPS Note: All 20 programs responded. $ We refer out clients to whatever program they need to be placed in, be it board and care or skilled nursing facility, or addiction recovery, etc. $ We will refer to whatever resources are needed (e.g., Institute of Aging, Blind Center, VA if DD219 obtained, transitional housing programs, outpa- tient substance use treatment) $ "Whatever it takes" approach $ Workforce development, legal services $ Work to get folks connected to substance abuse treatment services and disability advocacy groups locally, as well as ongoing connections to mental health service providers Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 19 Figure A8. Discharge Location "Other" responses included: $ Family reunification NUMBER OF PROGRAMS Permanent housing $ Short-term procedures, deceased 16 $ Clean-and-sober living Continued homelessness $ Emergency shelter, same building 16 $ Family/friends, board and care, room rental Transitional housing 14 Skilled nursing facilities 12 Treatment facilities 12 Other (please describe) 6 , Note: Seventeen of the 20 programs responded. California Health Care Foundation www.chcf.org 20 Appendix B. California Medical Respite Programs – Program Detail TYPE OF NUMBER AVERAGE LENGTH LOCATION SETTING MODEL STAFFING OF BEDS OF STAY Cottage Santa Barbara Shelter- Medical 1 RN (full-time) 10 90 days Recuperative Care based 1 RN (part-time) Hospitality House Nevada City Stand- Social 1 CM 14 60–90 days alone 1 Shelter manager 1 Program director 1 Grant manager 1 Outreach manager Illumination Orange, Stand- Social- 1 LVN medical coordinator 200 LA: up to 1 year; Foundation Los Angeles, alone medical Orange: 17 days; 1 CM and the Inland Inland Empire: Empire 1 Therapist 30 days 1 SUD counselor support staff 24/7 Nonclinical staff* LifeLong Medical Care Berkeley Shelter- Social- 2 RNs (weekdays) 27 36 days based medical 1 RN (weekend) 1 MD (1 day/week and on call) LCSW (1 day/week)* 2 CMs 1 Site manager Petaluma Petaluma Shelter- Social- 1 CM 6 14 days Recuperative Care based medical 1 RN Philip Dorn Concord Shelter- Social- 1 MD 24 42–56 days Respite Center based medical 1 RN 1 Dentist (2–3 times/week) 24/7 Nonmedical support staff* Recuperative Care, Los Angeles Stand- Social- 1 MD 96 6 months– Martin Luther King Jr., alone medical 2 years 2 NPs Medical Campus 11 RNs Medical assistants* CNAs* CMs* Social workers* Nonuniform security* Housekeeping and food service *Unspecified number of staff. Note: CHW is community health worker; CM is case manager; CNA is certified nursing assistant; LCSW is licensed clinical social worker; LVN is licensed vocational nurse; MD is doctor of medicine; NP is nurse practitioner; PA is physician assistant; RN is registered nurse; SUD is substance use disorder; WPC is Whole Person Care pilot. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 21 TYPE OF NUMBER AVERAGE LENGTH LOCATION SETTING MODEL STAFFING OF BEDS OF STAY San Francisco San Francisco Stand- Medical 6 RNs 75 14–56 days Medical Respite and alone 1 MD medical director Sobering Center 4.5 NP/PA 1 Nurse manager 3 Social workers 1 Behavioral health supervisor 7 CHWs 3 Medical assistants 1 Mental health resource specialist Santa Clara Medical San Jose Shelter- Social- 1 MD 20 20–30 days Respite Program based medical 3 RN/LVNs 1.5 Social workers 1 Psychologist 0.2 Psychiatrist 0.1 SUD counselor 1 CHW Street outreach team* St. Joseph Health Eureka Stand- Social- 1 RN 14 21 days Humboldt Medical alone medical 1 CHW Respite Program 1 Social worker 24/7 Nonclinical staff* The Gathering Inn Auburn Stand- Social 1 Site manager 12 42–90 days alone 1 Housing manager CM* 24/7 Nonclinical staff (WPC)* *Unspecified number of staff. Note: CHW is community health worker; CM is case manager; CNA is certified nursing assistant; LCSW is licensed clinical social worker; LVN is licensed vocational nurse; MD is doctor of medicine; NP is nurse practitioner; PA is physician assistant; RN is registered nurse; SUD is substance use disorder; WPC is Whole Person Care pilot. California Health Care Foundation www.chcf.org 22 Appendix C. Glossary Activities of daily living (ADL). The tasks of everyday In Lieu of Services (ILOS). Medically appropriate and life. Basic ADLs include eating, dressing, getting into cost-effective alternatives to services covered under or out of a bed or chair, taking a bath or shower, and the State Plan. These are optional services for Medi- using the toilet. Cal managed care plans to provide, and optional for managed care enrollees. California Advancing and Innovating Medi-Cal (CalAIM). A multiyear initiative by DHCS to improve Measure H. The Los Angeles County Plan to Prevent and the quality of life and health outcomes of our popula- Combat Homelessness creates a one-quarter percent tion by implementing broad delivery system, program, sales tax, which generates funds specifically for fund- and payment reform across the Medi-Cal program. ing homeless services and short-term housing. California's Section 1115(a) Medicaid Waiver, Medi- Palliative care. Specialized medical care that focuses on Cal 2020. The Medi-Cal 2020 Demonstration aims to providing patients relief from pain and other symp- transform and improve the quality of care, access, and toms of a serious illness, no matter the diagnosis or efficiency of health care services for over 13 million stage of disease. Medi-Cal members. Permanent supportive housing (PSH). An interven- Coordinated entry system (CES). Facilitates the coor- tion that combines affordable housing assistance dination and management of resources and services with voluntary support services to address the needs through the crisis response system. CES allows users to of chronically homeless people. The services are efficiently and effectively connect people to interven- designed to build independent living and tenancy tions that aim to rapidly resolve their housing crises. skills and to connect people with community-based health care, treatment, and employment services. Electronic health record (EHR). A digital version of a patient's paper chart. Section 8 voucher. Rental assistance funded by the US Department of Housing and Urban Development and Enhanced care management (ECM). A whole-person, administered by a local public housing authority to interdisciplinary approach to comprehensive care man- help households with low income pay their rent. A agement that addresses the clinical and nonclinical tenant with a voucher pays a predetermined portion of needs of high-cost, high-need managed care mem- rent, and the Section 8 program pays the remainder of bers through systematic coordination of services that the rent directly to the housing provider. is community-based, interdisciplinary, high-touch, and person centered. Vulnerability Index – Service Prioritization Decision Assistance Tool (VI-SPDAT). A "supertool" that Federally Qualified Health Center (FQHC). Community- combines the strengths of two widely used existing based health care providers that receive funds from assessments. The Vulnerability Index, developed by the HRSA Health Center Program to provide primary Community Solutions, is a street outreach tool cur- care services in underserved areas. rently in use in more than 100 communities. Rooted Homeless Management Information System (HMIS). A in leading medical research, the VI helps determine local information technology system used to collect the chronicity and medical vulnerability of people client-level data and data on the provision of housing experiencing homelessness. The Service Prioritization and services to homeless individuals and families and Decision Assistance Tool is an intake and case man- those at risk of homelessness. agement tool in use in more than 70 communities. Based on a wide body of social science research, the Hospital community benefit dollars. Initiatives and tool helps service providers allocate resources in a activities undertaken by nonprofit hospitals to improve logical, targeted way. health in the communities they serve. Medical Respite: Post-Hospitalization Support for Californians Experiencing Homelessness www.chcf.org 23 Endnotes 1.California Department of Health Care Services (DHCS). "California Advancing and Innovating Medi-Cal." Last modified May 5, 2021. 2.Staff. National Health Care for the Homeless Council. "Medical Respite/Recuperative Care." Accessed March 2021. 3.National Health Care for the Homeless Council, Standards for Medical Respite Programs (PDF), October 2016. 4.California DHCS. Fact Sheet: In Lieu of Services (ILOS) (PDF), April 2021. 5.Kelly M. Doran et al., "Medical Respite Programs for Homeless Patients: A Systematic Review," Journal of Health Care for the Poor and Underserved 24, no. 2 (May 2013): 499–524. 6.National Institute for Medical Respite Care, Medical Respite Literature Review: An Update on the Evidence for Medical Respite Care (PDF). March 2021. 7.Stefan G. Kertesz et al. "Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons." Journal of Prevention and Intervention in the Community 37, no. 2 (2009): 129– 42. 8.Dan Shelter and Donald S. Shepard. "Medical Respite for People Experiencing Homelessness: Financial Impacts with Alternative Levels of Medicaid Coverage." Journal of Health Care for the Poor and Underserved 29, no. 2 (May 2018): 801–13. 9."Providing Medical Respite for People Experiencing Homelessness During the COVID-19 Crisis," webinar, Center for Health Care Strategies, August 11, 2020. 10.Harder+Company Community Research, Recuperative Care in Los Angeles County: Strengths, Gaps, and Opportunities (PDF), UniHealth Foundation, July 2020. 11.Lori Solomon, "Fast Fact: Hospital Community Benefit Dollars Can Benefit Community Development," Building Healthy Places Network, September 6, 2016. 12.Los Angeles County Homeless Initiative. "History." n.d. Accessed March 2021. California Health Care Foundation www.chcf.org 24