Sutter Medical Center Sacramento - Interim Care Program

The Interim Care Program (ICP) provides shelters in Placer and Sacramento counties that offer homeless men and women a place to recuperate from their medical conditions following hospital discharge. The same program, but under a different name “the Transitional Care Program (TCP)” is offered in Solano County. Without this innovative and collaborative program, many homeless adults would be discharged to the street or cared for in an inpatient setting. The program provides patients with a place to stay while they heal and also links them to vital community services. ICP has produced impressive client outcomes by providing “wrap-around” services including connection to a medical home, enrollment in benefits and other programs, and support services for clients.

Overview

The Interim Care Program (ICP) provides shelters in Placer and Sacramento counties that offer homeless men and women a place to recuperate from their medical conditions following hospital discharge. The same program, but under a different name – the Transitional Care Program (TCP) – is offered in Solano County. Without this innovative and collaborative program, many homeless adults would be discharged to the street or cared for in an inpatient setting. The program provides patients with a place to stay while they heal and also links them to vital community services. ICP has produced impressive client outcomes by providing “wrap-around” services including connection to a medical home, enrollment in benefits and other programs, and support services for clients.

The ICP is designed to offer homeless patients a clean and safe place to heal for up to six weeks, providing comprehensive wrap-around services such as behavioral health services, permanent housing, and supported entry into a “medical home” in the community. Recent enhanced services include transition/processing meetings on-site each week facilitated by a counseling intern to address mental health issues and concerns. This program would not be possible without partnerships with local federally qualified health centers like WellSpace Health in the Sacramento region and La Clinica in Solano County.

In addition, Sutter Medical Center and WellSpace Health provide a five-bed Interim Care Program “Plus” (ICP+) for discharged patients. ICP+ is an enhanced version of the ICP, increasing the level of need and accommodating greater support for activities of daily living compared with the ICP.

Impact

The “wrap-around” services provided and the unique collaboration with community-based service providers have resulted in the program being cost-efficient while improving the health outcomes of its participants. The interventions significantly change client utilization patterns, improving clients’ quality of life, providing them with a healthy home in the community, and providing the health care system a significant return on investment. The utilization of both inpatient days and emergency department visits is significantly reduced while individuals are in the program and for six months post-program. In Sacramento and Placer counties, more than 928 patients have successfully discharged from this program, with an average length of stay of 23 days. The ICP provides an 81 percent reduction in inpatient bed days and 33 percent reduction in ED visits. This successful program recently received statewide recognition on California Public Radio. In Solano County, more than 75 clients have been served by the TCP. Of those served by this program, 100 percent of the clients enrolled in eligible programs, 60 percent connected to medical homes, and 60 percent have a new source of income. In 2012, 43 individuals were accepted into the TCP. Of these clients, 19 successfully completed the program and were linked to primary care services, health insurance, and a source of income. Eighty-four percent of these clients were linked to transitional housing or permanent home.

Challenges/success factors

The challenges presented by this patient population are universally unacknowledged outside of the hospital community. Local hospitals in Sacramento, Placer, and Solano counties wanted to be involved in creating a solution that would provide respite housing and, more important, focus on developing a community-wide approach to providing necessary services to the homeless population. After these efforts were initiated and fine-tuned at Sutter Medical Center, Sacramento, ICPs were then started in Solano and Placer counties. As a result, the program has made great progress in connecting a traditionally underserved and vulnerable population to medical care and important resources they wouldn’t have access to on the streets. The ICP model has proved to be a major success, not just for the participating hospitals but, more importantly, for the community as a whole.

Contact:

Gwendolyn Jenkins
ICP Program Manager
WellSpace Health
jenkins@wellspacehealth.org

Angelina Parker
WellSpace Health
aparker@wellspacehealth.org

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