For the better part of a decade, Barbara Cheiker made her home in squalid conditions next to a busy Northern California freeway. The hardships were unimaginable. Even as she prevailed in a hard-won battle for sobriety, Cheiker was diagnosed with congestive heart failure and various mental health crises.

Each time she was discharged from a hospital or rehabilitation center, she returned to her place without a plan or an advocate. But last year, after she was treated for a serious cut on her hand that led to a dangerous infection, things went differently.

Following discharge from the emergency room for her hand injury, Cheiker, 60, was referred to Santa Clara medical respite program, which is part of Santa Clara County’s Valley Homeless Healthcare Program (VHHP). The medical respite program provides two to four weeks of room and board in a post-acute care recuperative setting and access to comprehensive medical, social, and behavioral health services. She credits it with helping turn her life around.

“When I first entered medical respite, I was relieved to go there instead of back on the street,” Cheiker said. “Before, I never got the information I needed about what was going to happen after I was discharged. In medical respite care they helped me figure out where I would go next. And I felt I had some control because they left the decision up to me.”

Medical respite programs, also referred to as recuperative care, emerged in the 1980s, and now there are about 100 programs in 29 states. They generally operate in freestanding and shelter-based facilities or are attached to a hospital system. Some focus only on medical care, while others also offer a medical-social program that handles mental health and unmet social needs.

Across California, no two medical respite programs operate the same way. Differences exist in funding sources, in whether they are affiliated with a hospital or the county government, and in the precise model of care they adopt. VHHP’s medical respite care, for instance, is one of the few programs that offers mental health services on-site. Each program is designed to reflect the needs of the local community and partner agencies.

$17 Million in Savings

The Illumination Foundation, based in Orange County, runs one of California’s largest medical respite care programs. It reports that for 1,200 clients with severe mental illness, its medical respite care program reduced dependence on emergency rooms and law enforcement and resulted in fewer hospital readmissions, more opportunities to get connected with ongoing care and support services, and increased chances to seek transitional housing. The approach saved more than $17 million in medical costs over an 18-month period for CalOptima, the organized health system for low-income adults and children in Orange County.

A growing number of experts are urging that existing programs be expanded and new ones started. A leading voice in that movement is the National Health Care for the Homeless Council (NHCHC), a national network of more than 10,000 doctors, nurses, social workers, patients, and advocates working to eliminate homelessness. The council provides support to more than 200 health centers and Health Care for the Homeless programs in all 50 states.

The mental health therapy, the support with medical care, being able to rest, and not having to worry about where I was going to lay my head and if I was going to be safe — that was such a relief.

—Barbara Cheiker

In July 2020, NHCHC launched the National Institute for Medical Respite Care, which seeks to advance best practices, services, and knowledge in recuperative care. The institute works with hospital associations, health care plans, and state Medicaid agencies on integration and expansion of recuperative care services within complex systems of care.

Currently, California’s medical respite programs are funded primarily through hospitals with community benefit grants as well as a few direct contracts with hospitals and managed care plans. Whole Person Care Pilot programs, led largely by county agencies, are overseen by the California Department of Health Care Services to support people with complex needs, including those experiencing homelessness and high users of Medi-Cal with poor health outcomes. The Whole Person Care program will end in December 2021 and transition to a newer initiative — CalAIM, the California Advancing and Innovating Medi-Cal program. CalAIM charts a clear path for managed care to support medical respite care and other services for people experiencing homelessness.

Deciding to Ask for Help

Guests at the 23-bed VHHP medical respite program receive comprehensive psychological and social assessments that help staff prioritize their needs and treatment options. Soon after arriving, Cheiker met with Aleksandra Ceprnic, a psychologist trainee on staff. Together, they forged a plan that included referrals she would need after finishing her respite care stay. Ceprnic referred Cheiker to LifeMoves, a community partner that offers medically fragile people experiencing homelessness a long-term stay in a motel that includes three meals a day.

“The first big step for people on the street is to make a decision to go and ask for help,” Cheiker said. “Aleks let me decide what I needed, and we worked on my heart and my infections, including showing me how to take my medications. The mental health therapy, the support with medical care, being able to rest, and not having to worry about where I was going to lay my head and if I was going to be safe — that was such a relief.”

The Illumination Foundation places one-third of its clients in transitional housing after medical respite. The 12-year-old program has 250 beds in facilities scattered across Los Angeles, Orange, Riverside, and San Bernardino counties. In each county, the program operates differently. In Orange County, hospitals refer discharged patients to medical respite care, and Illumination collaborates with the county to get those with acute medical issues approved by the local Whole Person Care pilot to receive respite services. In contrast, Los Angeles clients can self-refer to the Illumination program and stay for up to a year while awaiting housing.

Illumination offers recuperative care, social services, children’s services, and mental health therapy. The program is in expansion mode because the region has so many who need complex care and are experiencing homelessness.

Acute Health Care Needs Surface Chronic Illnesses

“The need is huge,” said Pooja Bhalla, Illumination’s chief operating officer. “Medical respite helps with acute care services where we assess if they have hypertension, diabetes, asthma, anxiety, among other things. We often find out someone has these previously undiagnosed underlying conditions when they come to us with something like a fractured foot.”

Clients diagnosed with terminal illnesses are referred to hospice care and offered housing. Respite care meets their needs in the gap, ensuring they take their medications and get necessary health and support services.

Illumination is different from other respite programs because it offers its own housing. About 30% of its Orange County clients are placed in one of 35 single-family homes occupied by six guests, or they move into one of 20 apartment units. The organization houses about 450 clients whose rent is covered by US Housing and Urban Development vouchers. The Federal Emergency Management Agency has funded some of this housing during the COVID-19 pandemic, but support mostly comes from the partner agency in each county. People are permitted to stay permanently. Illumination is searching for similar options in Los Angeles County.

“Medical respite is not the be-all and end-all, but it’s very important to have a program that helps clients ultimately move into housing,” Bhalla said. “If we discharge them back to the street, we will never break the cycle of homelessness and repeated use of ER and hospital services. It is a critical component of the system of care needed to address health care needs for individuals experiencing homelessness.”

Medical Respite in the Rural North

Homelessness and related issues are not limited to urban areas. About 270 miles north of San Francisco, Humboldt County lacks industry and offers few job opportunities. Its homelessness rate is 1% — 16 times the national average.

The medical respite program attached to Providence St. Joseph Hospital in Eureka fills the gap when unhoused people have medical needs. It operates 14 beds in a facility where clients stay for 21 days after discharge from the hospital. Launched in 2010 as a grassroots project with five beds, the program has grown as needs increased.

“Our goal is to reduce hospital stays and connect them with a primary care provider and transition them to a camp, a sober living situation, or a residential treatment program or temporary housing,” said Joy Victorine, a social worker and manager of the transitional and community program.

The program is funded by the hospital and through a Medi-Cal managed care plan that serves Northern California counties. It partners with local homelessness advocate Betty Kwan Chinn, who runs a shelter and a village of shipping containers that have been adapted as living spaces for up to 40 people to respond to a critical shortage of housing.

Providers hope that CalAIM and one-time capacity-building grants will provide new sources of comprehensive funding to extend and expand these programs and add services, beds, and longer stays.

Victorine shared the story of an older person who is able-bodied but hobbled by a serious substance use disorder. After local law enforcement officers persuaded him to seek help, he agreed to medical respite care that offered wraparound services. A few months later, the man is in recovery, Victorine said.

“In a small community like ours, it’s really important to establish relationships and customize our model,” Victorine said. “We aim to serve clients so they can make small improvements that lead to life-changing improvements. We measure success in small increments.”

Measuring the Return on Investment

What medical respite programs have in common, as Bhalla emphasized, is that each serves a huge need. Providers hope that CalAIM and one-time capacity-building grants will provide new sources of comprehensive funding to extend and expand these programs and add services, beds, and longer stays.

The Illumination Foundation data underscore the fact that, while investment in medical respite care is a cost-saving activity in the long run, its value more importantly can be measured in lives extended and improved.

Six months after receiving medical respite care, Barbara Cheiker is living in temporary housing at an urban motel. She manages her own medications, regularly sees a cardiologist with the help of a transport service, coordinates with her case manager, and speaks weekly with Ceprnic. Their connection remains strong and centers her, she said.

“I’m suggesting medical respite to everyone I see if they have a medical or psychological need,” Cheiker said. “I pass on my social worker’s number. I’m so glad I went to respite care, and I would recommend it to others who need it to manage their diabetes or other conditions.”

You can learn more about medical respite programs and how they are becoming a growing part of the homeless services continuum throughout California through a landscape report recently published by CHCF.

Padma Nagappan

Padma Nagappan is a journalist who covers health, environment, and agriculture. Within the health beat, she focuses on public health issues, health impacts of environmental issues, medical advances, and medical research. She has reported on substance abuse and the opioid crisis, health disparities, cancer, mental health, and drug interactions. Her stories have been published in media outlets in the US and UK, including Everyday Health, Dermatology Times, US News & World Report, New Scientist, TakePart, MedShadow, Ag Alert, SugarOnline, San Diego Union-Tribune, and KPBS TV and Radio. Read More

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