Following discharge from a hospital, people experiencing homelessness are often still too sick or frail to successfully recover from their illness or injury while on the street or in a shelter. Many return to the emergency department (ED) or hospital to address lingering symptoms or complications. As a result, communities across California are implementing recuperative care programs (also called medical respite care) to better support the recovery needs of people experiencing homelessness following hospital discharge. 

Recuperative care programs vary in size and services. In addition to providing a safe place to recover, many programs connect people who are unhoused to social services, health insurance, medical care, and, ideally, interim or permanent housing. Despite the best efforts of recuperative care staff, discharging individuals directly to permanent housing is often impossible due to affordable housing shortages and the challenges of placing people needing high levels of care into appropriate settings.

In Orange County, California, three local organizations are collaborating to more effectively connect people residing at a local recuperative care facility directly to permanent housing. Illumination Health + Home (formerly Illumination Foundation), a homeless services and recuperative care provider; CalOptima Health, a local Medi-Cal (Medicaid) managed care plan; and the Orange County Health Care Agency (OC-HCA), the local health jurisdiction, are partnering to create a comprehensive continuum of health and social services, particularly for their clients with the highest need or highest risk. To achieve this goal, the partners are piloting efforts to exchange data to identify people with high health care utilization, strategically integrate newly reimbursable Medi-Cal services, and work with the local housing authority to reserve appropriate housing vouchers for pilot participants.

This profile explores lessons from the Orange County team’s pilot program to create a more effective pathway to housing for people experiencing homelessness who are receiving recuperative care. The team participated in Partnerships for Action: California Health Care & Homelessness Learning Collaborative, funded by the California Health Care Foundation and led by the Center for Health Care Strategies.

Pilot Overview

The three partners in the Orange County pilot team came together to secure permanent housing for people with high health care utilization residing at Illumination Health + Home’s Fullerton Navigation and Recuperative Care Center. Their pilot effort focuses on improving the health and housing status of clients while also demonstrating potential Medi-Cal cost savings.

The Orange County team’s pilot effort strategically aligns with CalAIM, California’s Medi-Cal transformation initiative, which created newly reimbursable services to support the health and housing needs of Californians who are unhoused. These services include Enhanced Care Management (ECM) and select Community Supports, such as recuperative care, short- term post-hospitalization housing, housing deposits, housing transition navigation services, housing tenancy and sustaining supports (HTSS), and day habilitation. Coverage of these services allows recuperative care and homeless services providers, like Illumination Health + Home, to obtain Medi-Cal reimbursement from Medi-Cal managed care plans, like CalOptima Health, for their services.

To qualify for the pilot, people at the recuperative care facility need:

• Five or more ED visits within the past six months; and/or
• Three or more inpatient hospital visits within the past six months.

To connect eligible individuals to housing, the OC-HCA works directly with the Orange County Housing Authority to reserve mainstream housing vouchers for clients. Typically, people experiencing homelessness use the Coordinated Entry System (CES) to obtain housing vouchers designated exclusively for people experiencing homelessness, with the process in Orange County prioritizing individuals based on their length of homelessness and other factors. Through the pilot, people discharged from recuperative care are connected to housing more readily, regardless of their length of homelessness. This means that people with more complex needs participating in the pilot may be able to access permanent housing sooner when they transition out of recuperative care or short-term post-hospitalization housing. Exhibit 1 details a person’s journey from recuperative care to housing and the services they may access.

Exhibit 1: Overview of How a Client Moves from Recuperative Care to Housing

About the Cross-Sector Pilot Partnership

Each organization on the pilot team plays a specific role:

• Illumination Health + Home provides recuperative care and short-term post-hospitalization housing, and other Community Supports, like housing transition navigation services, housing deposits, housing tenancy and sustaining services, and day habilitation. They also provide ECM and primary and behavioral health care.
• CalOptima Health leverages its data analytics capabilities and access to claims data to identify people with high health care utilization for the program. Health plan staff provide a list of members who meet the high-utilization criteria and may benefit from recuperative care. CalOptima Health staff also contribute technical knowledge about CalAIM services, like ECM and Community Supports.
• Orange County Health Care Agency is responsible for assisting with data analysis to identify people for the pilot and match clients to vouchers. OC-HCA also leverages its strong relationship with the Orange County Housing Authority, and through that relationship they are able to work with their county government partner to reserve mainstream vouchers for clients in the program.

Initially, the team met weekly to discuss pilot progress and troubleshoot challenges. As the pilot progressed, they switched to monthly meetings, which helped team members show up more consistently. Later, they began hosting case conferences with the Orange County Housing Authority to review pending client documents, discuss client housing scenarios, engage in problem-solving, address questions, and streamline communication between the Orange County team and the Housing Authority.

Exhibit 2: How Data are Exchanged between the Partnering Organizations

Impact of the Pilot Program

Between July 17, 2022 and June 25, 2024, 92 people participated in the pilot and were connected to housing and support services. The team estimates that many of these people were matched to housing more quickly than if they had been matched to housing through the Orange County CES, which, as noted earlier, prioritizes people based on the length of homelessness and service needs but does not include other health care utilization metrics. Jordan Hoiberg, director of housing strategy and community partnerships at Illumination Health + Home, acknowledged, “This partnership brought the right people to the table to think through how to house some of the most vulnerable people more quickly.”

Lastly, the pilot strengthened relationships between partnering organizations and with the Orange County Housing Authority. As a result of the partnership, Illumination Health + Housing is now working with the Housing Authority about potentially pairing permanent supportive housing services funded through the local Continuum of Care with housing vouchers for people experiencing homelessness with serious and persistent mental illness. In addition, regular case conferencing between Illumination Health + Home and the Housing Authority has helped Illumination staff better understand how the Housing Authority operates. This, in turn, allows them to more effectively support their clients in navigating Housing Authority subsidies. It has also helped create more direct lines of communication between the two organizations, which eventually leads to both entities better serving their clients.

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Roger’s and Shawn’s Journeys Toward Better Health and Housing

Roger was a client at Illumination Health + Home’s recuperative care and short-term post-hospitalization housing program for many months. When Roger entered recuperative care, he had concerns about his health (including type two diabetes and chronic back pain), legal issues, finding housing, and denial of Social Security Disability Insurance. During his stay, Illumination staff help him manage his medications, enroll in Medi‑Cal, and connect with a primary care provider. In addition, Roger worked with staff to learn to budget, manage his stress, and be a good tenant. The team at Illumination Health + Home worked with a local homeless court to clear warrants for his arrest. Eventually, Roger received a housing voucher and successfully moved into an apartment. He continues to receive housing tenancy and sustaining services through Illumination Health + Home.

Shawn, another Health + Home client, experienced 10 years of homelessness and repeated emergency department visits related to an underlying heart condition. Through Orange County’s innovative cross-sector partnership, Shawn has achieved stable housing and restored health. Roger’s and Shawn’s stories underscore the power of cross-sector partnerships in improving the lives of people who are unhoused. Watch the video below to learn more.

Photo Source: Bhalla, P. and Hoiberg J. (2024) Our CalAIM Journey: Challenges and Opportunities [Presentation]. California Recuperative Care Symposium. Video developed and produced by the California Health Care Foundation.

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Lessons on Cross-Sector Collaboration

The Orange County team’s collaborative work resulted in key lessons on cross-sector collaboration, such as:

• It is important to remain nimble. The Orange County team started with a clear plan for how data would flow between the partnering organizations. During the project, CalOptima Health and OC-HCA’s Business Associate Agreement expired. It took months to reinstate the agreement, and in the meantime, the team created a workaround for how data would flow between the partnering organizations to identify clients for the pilot.
• Cross-sector partnerships facilitate cross-sector learning. The two-year pilot and participation in the learning collaborative helped team members understand more about the work each other does to serve clients more effectively. For example, CalOptima Health staff learned more about housing vouchers, the importance and interconnectedness of housing navigation and tenancy and sustaining services, and how health plans can better support members accessing resources to stay housed. The Illumination Health + Home team learned about public housing authorities and how vouchers are administered, which will help the organization develop relationships with other housing authorities.
• Case conferences can facilitate stronger organizational partnerships. Toward the end of the project, Illumination Health + Home started hosting case conferences with the Orange County Housing Authority. Case conferences focused on collectively identifying how to best ensure that people who obtained housing through the pilot could remain housed. It also helped Illumination Health + Home and the Orange County Housing Authority build a stronger relationship, while better integrating the Housing Authority into the pilot team. This, in turn, has led to more direct communication between the two organizations and their staff, which has helped them serve their shared clients more efficiently.

Next Steps

The Orange County team will continue to work together while also thinking about how to refine the pilot and expand their collaborative work. Together, they are focused on:

• Expanding their partnership to include other providers and communities. The team wants to connect with additional homeless services providers that can refer clients to the pilot program. They are also looking to engage with additional municipalities that have independent housing authorities — such as Garden Grove, Anaheim, and Santa Ana — about participating in the pilot.
• Evaluating the pilot and focusing on quality improvement. Currently, the team is seeking to better understand housing retention and housing exits (i.e., why they left their housing placement) for clients housed through the program. The team plans to use this information to assess if additional supports are needed for clients once they are housed and if inclusion criteria for the program should be adjusted. 
• Increasing access to recuperative care and housing. The partnership has led to additional opportunities for collaboration. With support from CalOptima Health, Illumination Health + Home recently launched a first-in-the-nation recuperative care program for children and their families. In addition to that, Illumination Health + Home has also been working with the Orange County Housing Authority to match select clients participating in the pilot to permanent supportive housing, which includes rental assistance and life-long supportive services.