Last year, the District had fewer than 50 “medical respite” beds for people experiencing homelessness who are too sick to be living on the street or in a shelter but not sick enough to be in a hospital or nursing-home setting. There were 34 for men at Christ House and 12 at Patricia Handy Place for Women. Then, in October, Hope Has a Home opened two new facilities, each providing 8 beds. Four more homes are planned to open within the next year.
When the program receives a referral call for a homeless man with complex medical needs, the program’s social worker, Arsiema Yeibio, is often his first point of contact. “Usually he’ll have a bunch of questions,” Yeibio said, from what the program could provide — a safe bed in which to heal and assistance in potentially securing permanent housing — to its standards. The program is low-barrier, so while there are behavioral requirements, sobriety and medication adherence for a mental-health condition are not among them.
Hope Has a Home committed to opening 48 medical respite beds in the District, doubling the city’s capacity for this service. The program was launched by AmeriHealth Caritas D.C. and Volunteers of America Chesapeake & Carolinas (VoA-C), the largest Medicaid managed-care organization in the District and a branch of one of the nation’s largest human services organizations. AmeriHealth Caritas D.C. and VoA are working in partnership with Unity Health Care, which has a long history providing healthcare to people experiencing homelessness, and Pathways to Housing, a homeless services organization that coordinates outreach, housing placements, and healthcare under a “Housing First” model.
Respite care can exist on a spectrum, said Dr. Catherine Crosland, the medical director for Hope Has a Home. Sometimes someone experiencing homelessness may be referred to respite care for just a short-term stay to prep for a colonoscopy or get their HIV medication regimen under control, while others may have been recommended long-term bed rest after a heart attack. Hope Has a Home and other programs place a large emphasis on trying to secure housing for their residents. “It’s a perfect example of housing as healthcare, that housing will provide stability and support that they will never find in the shelter setting,” Crosland said.
Karen Dale, CEO of AmeriHealth Caritas D.C., said the organization likely covers 10 – 15% of D.C.’s homeless population, and she has long observed the price, both financial and human, of that community’s interactions with the healthcare system.
“[I think about] how difficult it becomes to get them to stability. The more admissions and readmissions that they have, the more they’re utilizing the emergency room as their primary care provider,” Dale said. “None of that is a recipe for health, much less good healthcare and positive outcomes.”
According to the 2019 Point-in-Time count, an annual survey that functions as a sort of census on the District’s population experiencing homelessness, 17.9% of the 4,915 adults counted reported living with a chronic health condition and 2.6% reported living with HIV/AIDS. Crosland said the coronavirus pandemic has only illuminated how vital the need is for respite care and permanent housing for the District’s homeless community.
In addition to setting aside hotel rooms for people experiencing homelessness who display symptoms of COVID-19, the Department of Human Services has designated one hotel, and is on track to add another, for proactively housing highly medically vulnerable individuals and individuals over the age of 80.
As of May 16, 312 individuals from shelter or unsheltered were in remote quarantine.
“I’ve been astounded,” Crosland said, “by just how much need there is.”
A program, and residents, in transition
Upon its completion, Hope Has a Home will more than double the number of respite beds in the District, though only AmeriHealth Caritas D.C. beneficiaries are eligible for them. Plans to open the 32 remaining beds promised by the project are being negotiated, taking into account complications caused by the pandemic. The original commitment was for all six homes to be operational by April 2021.
Coronavirus has posed a large challenge for Hope Has a Home, according to Jana Berhow, the vice president for D.C. programs for VoA-C. Hope Has a Home has remained open for intake for patients who have a COVID-19 negative test, making the lack of widespread testing a barrier. Berhow acknowledged, though, that testing is a point-in-time measure and that a resident who later tested positive would be provided with care. Dale said the drop in people admitted to hospitals and visiting the emergency room for non-COVID-19-related care has also notably slowed referrals to the home as less people have been seeking out non-emergent care. “We really thought we would be at full capacity for beds in both houses, and we aren’t because of COVID,” Berhow said.
According to Berhow, the healthcare system appears to be slowly resuming normal operations, as Hope Has a Home has received a handful of referrals in the past few weeks. Ability to secure PPE, widespread testing, and continued referrals will determine when a new set of homes will be able to be opened, something Berhow hopes can be accomplished by the end of the year. The two homes that have been opened only serve single men experiencing homelessness, but AmeriHealth Caritas D.C. and VoA-C have been discussing the next homes potentially serving single women or women with children.
The two existing homes operate in tandem. The first, located at Edson Place NE, is designated as a “Phase 1” home, in which an individual receives around-the-clock medical care from a nurse practitioner employed by Unity and licensed practical nurses employed by VoA-C. An individual will stay in Phase 1 until his cause of hospital admission, like a surgery or frequent hospitalization for a chronic condition, is resolved and he no longer needs assistance with tasks of daily living.
Jack Kline, who oversees the operations of both homes and acts as a liaison for VoA-C, says one of the most satisfying parts of his job is watching the men regain strength. “Some of that is recovery from a medical condition, but some of that is just getting three good meals a day and sleeping in a safe, warm bed every night,” he said.
Once they’ve healed, individuals move to the “Phase 2” home, located at Congress Street NE, and their medical needs continue to be monitored through out-patient visits at a Unity clinic. Altogether, the average length of stay at Hope Has a Home is four months.
In both phases, community support workers employed by VoA-C and Yeibio, the social worker, help the men feel comfortable in their new surroundings. Yeibio explained that she and the rest of the staff make sure each of the men has their necessities, like toiletries and clothing, to help them acclimate. They also help the men become comfortable with one another, as they share a kitchen, bathrooms and community spaces.
But Yeibio’s primary goal in Phase 2 is connecting residents to permanent housing.
As soon as a client enters Phase 1, Yeibo will ensure that he has an up-to-date profile in the Homeless Management Information System (HMIS) and assesses him using the VI-SPDAT, a survey that assigns individuals experiencing homeless a vulnerability score based on history of homelessness, medical conditions, mental illness, substance use, and other factors. The VI-SPDAT and information in HMIS helps create a priority list for those most in need of permanent housing. Finally, Yeibio attends the twice-monthly Coordinated Assessment and Housing Placement Meeting (CAHP), run by The Community Partnership for the Prevention of Homelessness, where prioritized individuals are matched to various housing programs.
Residents of Hope Has a Home tend to have a high vulnerability score, according to Kline, which often means they are matched to housing vouchers quickly. But sometimes they don’t score highly on the VI-SPDAT or their history of homelessness is not well-documented in the HMIS database, explained Carla Lester, the senior director of programs at Pathways to Housing. In this situation, Yeibio can utilize an alternative process known as case conferencing, which allows her to advocate, based on her professional judgment, for residents’ need for housing because of their medical vulnerabilities.
As Street Sense Media previously reported, DHS temporarily suspended the CAHP program in late March because of the pandemic, citing concerns for client and staff safety. According to Kristy Greenwalt, director of the Interagency Council on Homelessness, the CAHP program re-started on May 4 and plans to resume normal operations in a phased process.
First, District residents who are being proactively housed in the hotel set aside for older and medically vulnerable members of the homeless population are being prioritized for housing programs. Staff on site at the hotel are helping residents navigate the now virtual processes, for instance applying remotely for ID’s through the DMV. At this point, only community partners involved in this first stage of the re-starting process have received training on the new virtual processes. “As with anything that’s re-opening, it’s not like just turning a light switch on,” Greenwalt said.
Six men from Hope Has a Home have been matched with housing vouchers, out of the 14 who have been served by the home thus far. For those successes, Lester credits Yeibio’s process of building a relationship with a client from their first meeting in a hospital or nursing setting, ensuring he feels comfortable in the home, and then advocating on his behalf. “She’ll be there at the beginning, she’ll be there at the end,” Lester said.
Of the eight men not matched, some are still residing at Hope Has a Home, waiting for normal CAHP operations to resume. Others decided voluntarily to leave the program because they found sharing spaces difficult or didn’t like the structure. “When I speak to our clients, a lot of them don’t utilize the shelters, so they’re not used to being in close quarters with people,” Yeibio said. Kline added they have had to discharge a few men for violence or active substance use in the home, both of which broke the behavior guidelines the men agreed to and created an unsafe environment for staff and other residents.
In line with the low-barrier approach, men have the agency to engage in substance use outside of the home as long as it does not adversely affect their behavior in the home. But if someone is interested in mental-health or substance-use treatment, staff are ready to connect them to the appropriate resources. “They are adults; they have a right to choose. They have a right to be successful, and they also have a right to fail. It’s our intent to help them be better individuals, whatever that means for them,” Lester said.
After a client has been matched with a community partner, the process of applying for housing and then eventually finding a placement takes a while. Yeibio and the community support workers strive to improve their clients’ overall quality of life during their entire stay at Hope Has a Home, but especially during this waiting period. That may mean helping a client apply for food stamps or Social Security income, sending out job applications, or reconnecting them with a “core service agency” for behavioral health or a case manager with whom they had lost touch.
“Housing is housing, but we also want to work on those things that add life to someone’s years,” Lester said.
Though she is pleased with the impact Hope Has a Home has had thus far, Dale said a year’s worth of data is needed to conclusively measure its success. The critical metrics: hospital readmissions within 31 days of discharge from the hospital, preventable complications, and uses of the emergency department for a non-emergency issue, such as a urinary tract infection, that could be treated by a primary care doctor.
The results of meeting such performance goals will be threefold, Dale said. On the patient level, meeting these measures is an indication of an individual’s long-term stability. And from a financial standpoint, fewer emergency room visits and preventable hospital stays will lower costs for her organization. Additionally, the D.C. Department of Health Care Finance offers AmeriHealth Caritas D.C. and other Medicaid-managed care organizations a monetary incentive for meeting such goals.
Lester at Pathways to Housing said another standard of success might be examining individuals’ use of the healthcare system after being placed in housing through Hope Has a Home. “Are they more connected to their primary care provider? Are they refilling all of their medications on time? Are they getting their preventative screenings?”
Berhow added it was equally important to assess their residents’ personal wellbeing, something the Hope Has a Home team is already measuring using the Adult Needs and Strengths Assessment (ANSA), which includes questions about connections to meaningful daytime activities and non-professional support. “We do the ANSA as they come to us. We do it as they leave. We would hope to do it over some sort of longitudinal way eventually just to answer that question: ‘Did anyone get better because of the time they spent here?’” Berhow said.
At the program’s inception, Dale saw medical respite care as a way to build upon the District’s Continuum of Care, a coordination of resources aiming to prevent homelessness in the city. She said she dreams of Hope Has a Home eventually growing beyond its roots in AmeriHealth Caritas D.C.
“I want to see it grow to being a solution for the city,” she said.