Five Ways to Improve Recuperative Care in California

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Recuperative care programs, also known as medical respite care, provide room, board, and medical care coordination for people experiencing homelessness who are too ill or frail to recover on the streets or in a shelter but not sick enough to be in a hospital. Under the state’s CalAIM (California Advancing and Innovating Medi-Cal) Initiative, managed care plans have the option to cover medical respite care.

In September, Michelle Schneidermann, MD, director of CHCF’s People Centered Care team, addressed the inaugural California Recuperative Care Symposium in Sacramento. Her remarks have been adapted for this article.

Eighteen years ago, I was part of a team helping to launch a medical respite care program in San Francisco. That experience was one of the singular best parts of my professional career. When I left that position, I promised myself that no matter where I went, I would continue to find ways to work on medical respite care, and I have kept that promise. So today, almost two decades later, I am immensely grateful to join you all to reflect on how much collective impact recuperative care professionals have had in California.

In philanthropy, we like to think about impact in terms of data and measures. But as a clinician, I like to think about human impact — the changes our care makes in people’s lives. Measures are important, but stories sway hearts and minds.

And stories stick with us. I have vivid memories of the positive impact our program had on people we cared for many years ago.

There was Claire, who was referred to medical respite for wound care. During that stay, she agreed to have age-appropriate cancer screening and discovered breast cancer early enough to be cured through surgery.

A Mark of Success — Trust

There was Ann, a young woman with severe heart failure, likely caused by methamphetamine use, and post-traumatic stress disorder from a lifetime of interpersonal violence. For her, a marker of success was when she began to trust her health care providers. Ann worked with us to co-design a heart failure medication regimen that she could stick to, enabling her to avoid hospitalization for weeks or months at a time. Respite care meant she had a safe place to stay and was connected with behavioral health and domestic violence resources.

There was Rhonda, who was in her third trimester of pregnancy. She had a safe space to take blood thinners while working on a plan for interim housing for her and the baby she was expecting.

And there was Juan, who came to terms with his advanced lung cancer diagnosis. He reconnected with his children and met and spent time with his grandchildren before he passed.

Those of us who work in this space bear witness to patients experiencing tremendous trauma and suffering. It’s one of the reasons I’m so grateful for gatherings like this one and for programs like the Los Angeles Recuperative Care Network. Through these efforts, we can come together and share stories, successes, challenges, and innovative ideas. We can empathize and support one another. And we can draft blueprints for systems that can better serve the people to whom we provide health services.

Dramatic Growth in Medical Respite Programs

Over the past eight years, largely as a result of the Whole Person Care Pilot Program and CalAIM, the state’s capacity to serve unhoused people with complex needs has grown dramatically. We have state guidance, capacity-building funds, and collaboration between organizations that have not previously partnered. There is almost complete statewide adoption of recuperative care under CalAIM, with 224 recuperative care contracts in place and 1,600 people served as of the end of 2023. And yet, rapid growth does not come without challenges. I would guess that very few of us believe that we’ve fully figured things out, that our systems are working efficiently and effectively to meet the needs of homeless individuals, that we are spending our time and energy on the right things, and that the work is sustainable.

As you think about your work and the challenges ahead, here are five things I’d love to see California do to improve recuperative care access, experiences, and outcomes:

1. Promote Education

We are uniquely situated to ensure all key stakeholders — hospitals, clinics, street medicine teams, managed care plans, Continuums of Care, and, most importantly, people experiencing homelessness — understand the value of recuperative care and how to access it.

2. Focus on Quality

Recuperative care sites across California should follow the standards, guiding principles, and frameworks developed by the National Institute for Medical Respite Care. The institute has just developed a certification program that will launch in 2025. Certification presents a tremendous opportunity to lift all boats, since all programs will need to adhere to published standards.

3. Improve Transitions into Recuperative Care

We have decades of research showing that transitions of care from one site to another come with high risk for patients. To ensure safe and timely transitions from hospitals, clinics, and street medicine providers into recuperative care, we need better communication, improved data sharing, and streamlined processes and workflows.

4. Leverage Medi-Cal

Incentive programs like PATH CITED present opportunities to support infrastructure and workforce development. To fund the provision of services, respite care providers can contract with local managed care plans. Ideally, those plans will ensure responsive communication and coordination of care for their members, reduce administrative burdens so service providers can spend their time caring for patients, and offer flexible policies for authorizing services or extensions to minimize barriers to care.

5. Collaborate, Collaborate, Collaborate

We have an incredible opportunity to partner across sectors to ensure safe and successful exits from recuperative care. If we want people’s experience with homelessness to be rare and brief, health care and social services organizations must partner with the homeless response system. We need to get better at matching people to the right housing and services. This includes identifying programs that can serve patients with high needs, such as those who are older, have behavioral health conditions, or need advanced illness support or hospice care.

These are my ideas. You may have different ones. Whatever they are, I’m optimistic that the people working in the recuperative care movement can address the challenges we face to providing accessible and effective care.

As providers, community-based organizers, and managed care plan representatives, you know the feeling of experiencing a successful outcome with a patient, a family, or a community. How can we achieve more of those? Think of a specific person who was helped by the work of your teams. Carry those patients or clients in your heart, and let them inspire you.