People experiencing homelessness have an array of complex health and social needs, and health care organizations across the country are seeking ways to best support this population. California, with the highest homeless population in the nation, is at the forefront of using cross-sector partnerships to innovatively respond to this crisis.
With support from the California Health Care Foundation, the Center for Health Care Strategies (CHCS) launched the California Health Care and Homelessness Learning Community in November 2020 to bring together California-based health care providers, payers, and other organizations to share best practices related to health care for people experiencing homelessness. The learning community sought to build on opportunities that are now available statewide through California Advancing and Innovating Medi-Cal (CalAIM). This statewide transformational initiative, which launched in January 2022, is focused on improving care delivery and financing for people with complex health and social needs, including providing those at-risk of or experiencing homelessness with a variety of supports.
This blog post highlights examples shared within the learning community to illustrate how California health care stakeholders are partnering to implement care models like medical respite care, street medicine, and sobering centers. Other states looking to address the homelessness crisis can look to these partnerships as promising approaches to fill service gaps and improve care for people experiencing homelessness.
Medical Respite Care
Medical respite care (aka recuperative care) provides post-acute, short-term residential care for people experiencing homelessness. It offers a safe place for people to heal and provides supportive services and access to clinical care for individuals who do not require hospitalization but who also cannot recover on the street or in a congregate shelter setting. These programs are often enhanced through partnerships with various community stakeholders. Increasingly recognized as an impactful approach to filling one of the safety net systems’ largest gaps, California is leading the way for states to think about opportunities for Medicaid and partners, such as managed care plans, to support this work. Some examples include:
- Illumination Foundation, a non-profit that provides interdisciplinary services for adults and children experiencing homelessness in Southern California, operates a medical respite care program and partners with Molina Healthcare, a Medi-Cal (Medicaid) managed care plan, to address health-related social needs and provide stable shelter options for members experiencing homelessness. Illumination Foundation and Molina have benefited from close communication by holding weekly meetings where case managers and member service representatives discuss client progress and coordinate resources to prepare for discharge. These weekly meetings allow for an efficient process to address client health concerns, and directly connect clients in their respite program to Molina Medi-Cal primary and specialty providers and community resources.
- National Health Foundation, a non-profit that advances community-forward solutions to strengthen health at the neighborhood level and end homelessness, operates several medical respite programs for Californians to recover post-hospital discharge. One of its Los Angeles-based medical respite programs partnered with Clínica Romero, a local federally qualified health center that serves a largely Latino community, to offer COVID-19 vaccine pop-up clinics and testing sites for medical respite program guests. Currently, National Health Foundation and Clínica Romero are partnering to create a modular clinic on the medical respite campus that offers primary care services for program guests and the local community. Having these services onsite is essential to increasing health care access and creating a more integrated health care experience for communities that have been marginalized.
Street medicine refers to the delivery of health care to people experiencing homelessness in their own environment (e.g., on the street, in encampments or parks) and on their own terms. Teams are comprised of an array of providers, such as doctors, nurses, mental health specialists, social workers, and pharmacists who work collaboratively to meet the needs of people experiencing homelessness. In California, health care providers and payers have long recognized the value of street medicine and use a variety of partnerships to provide these services. For example:
- Health Net, a health plan in California, leverages their analytics team to support their street medicine team partners to verify eligibility and access relevant data. The data are used among the health plan and street medicine teams to identify gaps or needs of the people experiencing homelessness that they serve. Health Net and the street medicine teams may then determine strategies needed to fill gaps in care, for example, through refining the composition of street medicine teams. Once data are collected, gaps identified, and a partnership strategy is developed and funded, Health Net relies on the street medicine teams’ expertise to deliver care.
- Alameda County Health Care for the Homeless’ Street Health team partners with a local pharmacy to support dispensing medication on the street. Street medicine providers often face challenges navigating regulations and standards of care related to prescribing, dispensing, and administering medication outside of an office setting. To ensure patients can easily access medications for addiction treatment, for example, this partnership allows the pharmacy to dispense the controlled substance to the patient without a government-issued ID, something that many people experiencing homelessness often have difficulty obtaining. Instead, the pharmacy allows Alameda’s Street Health team to provide an identification letter that describes the patient and what they look like as an alternative to an ID.
Sobering centers are 24/7 facilities for individuals who are acutely intoxicated, nonviolent, and need a place to safely recover from alcohol and drug use. Lengths of stay are short and range from between four to 24 hours. Sobering centers offer a low-barrier service that includes care coordination and connection to resources, including referrals to shelters, substance use treatment, peer support, and other social and behavioral health services. Many sobering centers have built relationships with local community partners, particularly emergency and police departments, to generate buy-in for their care model, better integrate into the continuum of care, and support referrals both to and from the sobering center. For example:
- Exodus Recovery’s David L. Murphy Sobering Center and the L.A. City Fire Department have a partnership called The Sober Unit, which is a team that consists of a firefighter/paramedic, nurse practitioner, and case manager. They assess and provide medical clearance for patients to be redirected and safely transported to the sobering center instead of the emergency department (ED). As a result, patients receive the care they need and get connected to social services instead of being admitted to the ED, and the L.A. City Fire Department uses fewer resources to transport and wait at the ED for an open bed. The David L. Murphy Sobering Center also collaborates with local hospitals to support patient discharge plans and often shorten the length of stay by alleviating the pressure of hospital discharge planning.
Improving health care delivery, and ultimately health outcomes, for people experiencing homelessness takes cross-sector, collaborative partnerships among hospitals, community-based organizations, pharmacies, emergency services, and other key organizations. In California, offering medical respite care, street medicine, and sobering centers as a flexible service under CalAIM will enhance the capacity of current existing programs by expanding services, hiring higher credentialed staff, and providing further opportunities and new avenues for cross-sector collaboration. Other states can learn from this work in advancing care of people experiencing homelessness by recognizing the importance of partnerships and prioritizing these unique and flexible services as a valuable part of the care continuum.
Moving forward, look for lessons coming out of CHCS’ new initiative, Partnerships for Action: California Health Care & Homelessness Learning Collaborative, made possible by the California Health Care Foundation.