Chronic Care PLUS: Charting a path to permanent stability for chronically homeless ER super utilizers

Wednesday, June 1, 2016
Pavilion Ballroom (Hilton Portland)
John Kim (Director of Grants, Illumination Foundation)
In July 2013, St. Joseph Hospital and the Illumination Foundation embarked on a two-year pilot project intent on charting a path to stability for the most medically vulnerable clients experiencing homelessness. These clients were experiencing chronic homelessness and frequently utilized emergency department care at St. Joseph Hospital, in Orange, CA. Chronic Care PLUS, as the pilot was named, combined world-class medical care with post-hospital recuperative care, medical bridge housing, permanent housing, and retention services, all coordinated through intensive case management support. The project demonstrated a full-spectrum care system to break the twin cycles of hospital recidivism and chronic homelessness. St. Joseph Hospital and Illumination Foundation worked closely together to build a seamless discharge process to provide for all anticipated post-hospital needs of the client. Within Illumination Foundation, interdisciplinary care teams and housing coordinators worked closely together to ensure quality care and continuity of services. The combined collaborative work achieved Triple Aim outcomes of improved health and better patient experience at much reduced costs. This poster presentation will provide participants a roadmap including the process flow, composition of multidisciplinary teams, data collection, and cost avoidance to enable replication of the program in other locales. The presentation will also provide an overview of the challenges and lessons learned during the two-year pilot project.