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  • 1. Medical Respite Everywhere: Building our Future Respite Pre-Conference Institute: National Health Care for the Homeless Conference & Policy Symposium JUNE 2, 2010 SARAH CIAMBRONE LESLIE ENZIAN, MD ADELE O’SULLIVAN, MD Respite Care 101: An introduction for new providers or for programs that want to develop a respite program
  • 2. Goals for this session
    • Understand Respite Care and its history and context
    • Explore models of respite care
    • Review common characteristics of respite programs
    • Learn how respite care is delivered and why it is an essential component of the continuum of health care services for the homeless
    • Overview of admission, stay and discharge planning
  • 3. Goals continued
    • Learn how other programs have done it
    • View existing programs as resources
    • Learn about the Respite Care Provider’s Network
    • Learn how to get involved
  • 4. Context for Respite Care
    • Emergency shelters typically provide night shelter only
    • Guests arrive late afternoon
    • Line up for meal and shower
    • Emergency cot for the night
    • Shelters open doors at about 6am and guests are discharged to the street
  • 5. What happens when you are sick and homeless?
    • Shelters send all guests to the street in the early morning
    • Few have lobby privileges
    • Frequent and unnecessary use of emergency rooms
    • Exhaustion associated with making it through the day: no easy access to bathroom, bed, food, medication while feeling lousy
  • 6. Patient Story
  • 7. How would I walk the streets from early morning to late at night?
  • 8. Or climb into a top bunk at an Emergency Shelter?
  • 9. What is respite care as it applies to health care for homeless individuals?
    • Medical (“home care”) to a person who has no home
    • For persons who are “Too sick for shelter, not sick enough for hospital”
    • Respite care is an essential part of the continuum of health care services for homeless post-acute and chronically ill patients
  • 10. Medical times have changed
    • Hospital LOS is getting shorter
    • Hospitals are only for the very sick
    • Procedures which used to mean weeks in bed are now day surgeries or procedures
    • Day surgeries and day procedures are not scheduled for patients who do not have a safe place to recover
    • What is the average LOS in Boston?
  • 11.
    • Medical Respite Care fills the void in services.
    • Does Not Compete with existing programs that already care for patients who are homeless (nursing homes, rest homes, state hospitals)
    • Establish the niche and know the limits but remain flexible
    • Who will be served?
    • Define Admission Criteria to meet the needs
    If Respite Care is a substitute for Home Care for those without a home, what level of care does Respite provide?
  • 12. What is Respite Care as it applies to health care for homeless individuals? “Home healthcare for those without a home”
    • Medical/nursing (“home care”) to a person who has no home
    • Short term (LOS <3 weeks) for resolution of illness
    • For persons who are “Too sick for shelter, not sick enough for hospital”
    • Resource for hospitals, decreasing admissions and LOS
    • Respite Care is an essential part of the continuum of health care services for the homeless post-acute and chronically ill people of our cities and towns and rural communities
    • Not housing, but may link folks to housing resources
    Health Care & Housing Are Human Rights
  • 13. Definition of Respite Criteria (defined in Chicago at 1 st Gathering of Respite Care Providers Network 2000)
    • A service for ill or injured
    • Specialized service
    • A short term service
    • An innovative service
    • Wholistic care
    • A collaborative model
    • Consumer driven
    • (A continuum of respite programs)
  • 14. Ready for discharge from hospital 2010?
    • Hospital LOS brief. Hospitals only for the very sick
    • Reliance on home care for all when discharged from hospital
    • Families become care givers
    • Range of Care at home now includes IV therapy, PT/OT, peritoneal dialysis, oxygen, transfer to & recovery from chemotherapy, radiation, preparation for colonoscopy, pre-procedure prep, post procedure recovery, evaluation
    • How does one do this without a home?
    Health Care & Housing Are Human Rights
  • 15. Definition of Respite Care
    •   The concept of respite care is to provide a place of rest from the street for those persons who need 24-hour-a-day acute and post-acute care in a safe and dignified healing environment.
    • To provide recuperative care for homeless persons who are too sick for the streets or shelter, but not sick enough for the hospital.
  • 16. Defining the Scope of Care and Range of Services
    • Ideally dependent on the needs of the patients served, community needs
    • Practically dependent on funding, resources, space
    • What is reasonable? What defines the basic level of care needed for medical respite program?
    • Who are those that require this care?
  • 17.  
  • 18. Prevalence of Common Chronic Illness
  • 19. Respite Care does not compete with existing services or programs
    • If eligible for other programs or services, patients should go there:
    • nursing homes,
    • State Hospital
    • DMH Respite
    • Respite Care for Homeless patients fills the gap in services
    • Pressure on beds is high, so if eligible for other program, patient should go there
  • 20. MEDICAL RESPITE SERVICES
    • Acute medical care (by a nurse, physician, physician assistant, and/or nurse practitioner)
    • Medication (storage, dispensing, rarely pharmacy)
    • Case Management (benefits acquisition, housing placement, health education, etc.)
    • Onsite or referral for mental health/substance use treatment
    • Transportation
    • Food
    • Security
    • Laundry
    • In-kind (pastoral care, activities, haircuts, clothing)
  • 21. Core respite services offered
    • A safe place to prepare for procedures, recover from illness, trauma and surgery
    • Recuperate with medical monitoring
    • Nursing care varies from a few hours to 24/7
    • Medical care varies from a few hours /week to daily
    • Medical Detoxification for some programs
    • Support services may include: food, laundry, transportation, mental health support, medications, security, case management, referral to specialty care
  • 22. Flexibility in the model of respite care
    • Flexible model which continually changes and adapts to the needs of our patients
    • Expands to include a place for patients to spend the day, transportation provided
    • Flex the walls to fill the gap in services, whatever that may be
  • 23. McInnis House to and from housing
    • A safe place for patients to transition to housing and Housing First programs
    • A place to return to recover when newly housed and vulnerable
    • A place where one is known and belongs
  • 24. Models of Respite Programs
    • Free standing facility
    • Shelter based beds where guest stays in bed to rest
    • Nursing component, medical component
    • Motel rooms with medical monitoring
    • Family Respite (motel, family shelter)
    • Contracted service in a board and care facility
  • 25. MEDICAL SERVICES TYPE OF FACILITY Non-health care facility Health care facility Refer to shelter beds Motel/hotel vouchers Contract with board & care facility Shelter-based Respite unit Free-standing respite unit
  • 26. Two Primary Models with Numerous Variations Combining….
    • range of intensity and type of services with
    • different facility options
    • Freestanding respite units
    • Shelter-based models
  • 27. Leslie to compare portland, utah, etc as illustrations
  • 28. Leslie Respite Program Development
    • While essential, medical respite care is rarely funded
    • Most new and developing programs are shelter based
    • Even with a stand alone facility, there will be the need for shelter based respite care to supplement the needs
    • Lead in to Adele who will have one slide on funding- laying out the spectrum of possibilities referencing presentation later in the day.
  • 29. Adele: Licensure and her experience with pursuing funding and her program
  • 30. Advantages of a Free Standing Program
    • Ability to provide more comprehensive services– medical and non-medical with a more intense level of acuity
    • Respite program controls policies and procedures, and defines scope of care
    • Respite program controls environment (health and safety issues)
  • 31. Challenges of a Free Standing Program
    • Identifying adequate funding to support needed services and operations
    • Takes time
    • Finding an appropriate facility
    • Possible licensing and zoning issues
    • Possible conflict from neighborhoods (if a new facility)
  • 32. Advantages of Shelter Based Medical Respite Model
    • Uses expertise of existing programs (shelters for beds, health program for services)
    • Reduces facility costs by utilizing existing facility
    • May eliminate need for special licensing (depending on state law)
    • Encourages coordination and collaboration between agencies
    • Helps to demonstrate the argument for the need for respite care
    • Hospitals and other stakeholders benefit from having a safe place to discharge a patient to, may come to the table for the development of stand alone facility or expanded program
    • Demonstrates outcomes in making the argument for respite programs
  • 33. Challenges of a Shelter Based Medical Respite Care Model
    • Shelters and health programs may have differing philosophies- ongoing tension
    • Possible conflict over admissions policies and control of the beds
    • Health care program has little control over health and safety issues in shelter environment
    • Services are more limited, patients have to be quite stable, some patients are too sick to be in this model
    • Sobriety is challenged in a shelter where others are misusing substances
  • 34. Admission Criteria
  • 35. Re-Admission Criteria
    • Past experience at respite provides information about future stays
    • Patients with known past difficulties at respite: incorporate this into treatment plan to assure success with next admission
    • Treatment agreements, limit visitors, outside appointments, random urine screening
  • 36. Conditions of Stay for Patients
    • Structure of the day
    • Expectations of patients
    • Behavioral management
  • 37. Respite Care History
    • NYC Dr. Brickner’s Infirmary
    • Barbara McInnis House, Christ House and Interfaith House 1993
    • In 2000 10 Bureau of Primary Care respite programs
    • RCPN
    • Now 50 programs?
  • 38. Respite programs 2009
  • 39.  
  • 40.  
  • 41. Me to do Focus on hospital relationships and community partner
    • Hospital Rounding at two major hospitals in Boston
    • Fast Track from ED to respite
    • Evening and weekend ED admissions to reduce hospital admissions of homeless patients who do not require hospital level of care
  • 42. Balancing the need with census
    • Filling the beds
    • Assuring the mission
    • Balancing the needs with available beds
    • Pre-booked commitment to day surgeries or endoscopy
    • Shelter and hospital partners needs
  • 43. Medical stay-in beds
    • Care provided by HCHP shelter clinics provides discharge options with day rest prior to regular shelter beds
        • Medical stay in beds (men)
        • Medical stay in beds (women)

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