An $800,000 investment in a respite program that provides a place for homeless patients to recuperate after discharge has saved participating hospitals in Santa Rosa, CA, $17 million in the first three years.

  • Qualified patients get a bed in a ward in a federally qualified health center and three meals a day. The health center provides medical care and case managers who connect patients to community resources.
  • Hospital case managers identify patients who no longer meet inpatient criteria but are too sick to be released to the street, and contact the program’s intake coordinator to visit patients and enroll them in the program.
  • Representatives from the three hospitals and Catholic Charities, which administers the program, meet quarterly to discuss ways to work together.

Hospitals in Santa Rosa, CA, saved $17 million dollars in first three years after investing $800,000 in Catholic Charities’ Nightingale program that provides a place for homeless patients to recuperate after being discharged from the hospital.

The program targets patients who no longer meet inpatient criteria, but who are too frail and sick to be released to the streets and need extensive bed rest during a recovery period. In the past, the patients would have stayed in the hospital for weeks at a time or been discharged back to the street and ended up back in the ED, says Jennielynn Holmes, MPA, director of shelter and housing for the Catholic Charities of the Diocese of Santa Rosa.

The savings were calculated by multiplying the daily cost of hospitalization by the number of days patients would have been likely to stay in the hospital if they couldn’t go to the respite shelter, Holmes says.

Located in a federally qualified health center, the program houses the patients in a unit similar to a hospital ward. The program provides a safe environment where patients can have bedrest while they recuperate, she says.

Patients receive medication and medical care from the adjacent clinic. They receive three meals a day and have access to a TV room. The program also provides comprehensive case management for patient. A case manager helps connect patients with housing resources and other community benefits that can help them after they leave the shelter.

“We are not a medical program. The staff provides caregiving services, but the patients have to be able to provide most of their own care. We do remind them to follow their medication regimen. Most patients are not accustomed to a regular routine and they need reminders to take their medication,” Holmes says.

The program started in late 2011 with 13 beds for patients with low acuity. It expanded last year with another 13 beds for people with higher needs. Patients who need specialized care, such as wound care, receive it from home health staff. An adjacent clinic takes care of other medical needs.

Kaiser Permanente, Santa Rosa Memorial Hospital, and Sutter Medical Center funded the initial 13-bed program and continue to provide funding. Sonoma County began providing funds when the program expanded.

“Sonoma County was so impressed with the initial result that the Board of Supervisors agreed to provide funds when we wanted to expand to take patients with higher needs,” Holmes says.

When case managers at the participating hospitals identify a patient who is homeless, they contact the Nightingale program. Nightingale’s intake coordinator visits the patients in the hospital, assesses them for eligibility, explains the program, and begins to develop a relationship with the patients. “We have to be very careful about who we take because we don’t have the staff to care for patients with complex needs,” Holmes says.

After discharge, patients are transported to the shelter by taxi. Patients stay at the Nightingale shelter an average of 30 to 45 days. One patient who was terminally ill stayed for eight months. “We assess people regularly and as they become stronger and more mobile, we transfer them to another shelter,” she says.

The three major hospitals in the community were part of Nightingale from day one and helped develop the program, Holmes says. “They knew the community really needed the services and they were happy to participate,” she says.

Holmes visits each hospital quarterly and talks to the staff about what is working and what needs to be improved. “It’s a great opportunity to do troubleshooting and to collaborate on solutions for problems,” she says. Participants at the meetings include discharge planners, the head of social work, representatives from the quality department, and the person in charge of funding. “I want to find out how the program is working from both a clinical and a funding perspective,” she says.

Data from the Nightingale project is being included in an initiative by the University of Notre Dame and Catholic Charities USA to find the best practices in poverty reduction.

Holmes hopes the program can be replicated in other communities.

“We partner with the medical community to get these patients everything they need for a successful recovery. They treat the patients’ medical problems while we coordinate their social needs. We have achieved a great return on investment and are providing a service to the people who need it most,” Holmes says.