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The revolving door of homeless patients going through Yale New Haven Hospital (YNHH) was a source of mounting frustration for the hospital’s emergency department (ED), says hospital social work director Paula Crombie.

“They knew these patients on a first-name basis because the ED was their medical home,” she says.

The hospital had a hard time discharging the patients because they didn’t have a place to go. When it did, patients were pushed back into homelessness, where their symptoms would return and often worsen until they were right back in the ED.

A 2012 YNHH study of 113 homeless patients found that, within 30 days of their discharge, more than 30% returned to the ED and more than 50% were readmitted for inpatient care. The study was a catalyst for change.

“We needed to take a stand and see what we could do about breaking that cycle,” Crombie says. “We looked at possible solutions that would benefit both the patient and community.”

A hospital-guided task force of community stakeholders, including nonprofit homeless advocacy group Columbus House, led to a medical respite program for chronically homeless patients. The program opened its doors in October 2013 at Columbus House, which provides shelter, housing and related services for homeless residents.

The program is taking homeless patients out of the revolving door of repeat hospital and ED visits and placing them on the road to better health. According to a 2017 YNHH study, the 30-day readmission rate for respite patients dropped from that 2012 level of 50% to 16.7% by 2016. The average length of stay fell from 8.6 days in 2014 to 7 days in 2016. The hospital also estimated Medicaid savings of at least $12,000 for each patient enrolled in the respite program.

“Yes, it has saved money and reduced hospital stays and readmission rates, but it also gives the people the time they need to heal and get well,” says Columbus House CEO Allison Cunningham.

People like Douglass Rivera, who participated in the program last year following surgery for a serious knee injury. He now has permanent, supportive housing.

“I would have been on the street without respite,” he says. “With respite you don’t have to worry about anything but getting well.” He gives a “thumbs up to the staff for helping me get back on my feet again.”      

YNHH’s medical respite program is a big part of its multi-pronged effort to tackle homelessness in its communities – an effort that helped earn the hospital the 2017 Foster G. McGaw Prize for excellence in community service.

YNHH’s Crombie says the “environment changes” when homeless patients find a safe place to live.

“These are people who found themselves in a situation where they didn’t see any way out, and thing just got worse until somebody came and rescued them and they could see light at the end of the tunnel,” she says. “They work with us to be part of their own change, get their lives back together and manage their medical crises.”

More than 300 YNHH patients have received respite care since the program began. Their average length of stay is between four to six weeks.

It starts at the hospital bedside, where patients are interviewed to determine their eligibility for the program. Hospital social workers and care managers then work with respite staff to arrange post-hospital care at Columbus House, which provides 12 single rooms for eligible patients.

The patients can stay on site all day – unlike shelter clients at the building – and are served three meals a day. Staff create medical and housing service plans for them, connect them with primary care providers, arrange transportation to medical appointments and refer participants to behavioral health and employment services. 

“We start them on a housing plan the moment they come into respite,” says Columbus House’s Cunningham.

She credits YNHH for “putting so much time, attention and effort into this program.” She says the hospital recognizes the importance of address social determinants of health – like housing and homelessness – and “is a really important partner in our community – not just for Columbus House, but the community at large because it understands these issues.”

Social work director Crombie says the “core of our success is the partnership with a willing and effective community organization, like Columbus House.

The hospital can’t tackle community health issues in isolation, Crombie notes. “There are many community partners here,” she says. “We are just one spoke of the wheel.”