Yale New Haven Hospital – Working to End Homelessness

New Haven, CT
November 2017

Overview
The annual Point In Time surveys in Connecticut show that New Haven has the highest concentration of both individuals and families experiencing homelessness in the state. The paradigm shift from sheltering to re-homing people is becoming the norm, and Yale New Haven is working hard with a continuum of providers to develop and execute strategies to transform the care delivery model that, in turn, transforms lives. These strategies include:

• The Medical Respite program – This innovative program provides recuperative care to those who are homeless and exiting the hospital. In addition, the program lowers public health care costs by reducing unnecessary readmissions. Based out of the Columbus House shelter, referrals come from both YNHH and the Veterans Administration Hospital in West Haven. This 12-bed, single-room-occupancy program includes 24-hour supervision, on-site nursing care, health care referrals, transportation, and case management services.
• Overnight Warming Centers – Realizing a lack of shelter beds and safe spaces to go at night during the winter, the two shelter programs in New Haven teamed up with the faith-based community and YNHH to operate these warming centers. Locations include churches and overflow space at the hospital. YNHH provides physician assistants, blankets and other resources while the shelters utilize staff to inform those seeking these services, as well as transportation to them. Together we are engaging individuals with case management services in an effort to transition people into permanent housing.
• South Central Community Care Team – Yale New Haven is one of many partners that came together in 2014 to ultimately end homelessness. YNHH adopted the Earn Benefits Online portal for our social workers, which is a one-stop approach to assisting patients with accessing benefits vital to health and stability. YNHH also took part in the 100 Day Challenge to End Homelessness, coordinated by the United Way of Greater New Haven, which transformed the way services were provided to those experiencing homelessness.

Impact

• The Medical Respite program grew from 17 patients in 2013 to 97 in 2016, and realized a 50 percent drop in readmission rates compared to the same population not enrolled in this program. This same patient population is now more than 60 percent less likely to present in an emergency department after 45 days from initial treatment.
• Overnight Warming Centers saw in excess of 30 people per night during operation. These are individuals who would have otherwise been out of doors in sub-zero temperatures. These interactions allowed case managers from social services to engage people in creating action plans, while under medical supervision, in a safe and welcoming space.
• South Central Community Care Team successfully placed 102 individuals into permanent housing during the 100 Day Challenge in 2014. They also instituted a common software package, accessible by every social services agency in the region, to more effectively connect individuals experiencing homelessness to necessary benefits while sharing care plans, when this type of communication had previously not existed. This collaboration is part of a statewide effort that was able to effectively end chronic homelessness for veterans in 2016.

Lessons Learned
Individual organizations that had previously operated on an individual basis came together under a common goal, and in a short, 100-day period, achieved remarkable results. Regional collaboratives across Connecticut, acting on shared values and under a shared mission, moved the state’s chronically homeless veterans into housing. The lesson is clear: when we work together, we move from managing problems to solving them.

Future Goals
The initial three-year data illustrates the success of the Medical Respite care model, and Yale New Haven seeks to continue to reduce readmissions, lower length of stay, and improve long-term health outcomes for our patients experiencing homelessness. Achievements to date have led to Yale New Haven and Columbus House being inundated with calls from other health delivery organizations looking to transfer patients. YNHH’s short-term goals for the Medical Respite program are to increase the number of patients served by increasing the number of beds available in the program, as well as to provide an on-site physician, and funds are currently being sought to do this. This may include use of another location in order to operate more SRO units. Further, care models are being explored that could utilize relationships with local medical schools and/or training programs to provide for a larger care team while creating greater learning opportunities for students.

Contact: Kyle Ballou, Esq.
Executive Director
Telephone: 203-688-2503
Email: kyle.ballou@ynhh.org