w w w . a c m a w e b .

o r g

Community Collaboration – The Interim Care Project in Sacramento, CA

By Kate Tenney, RN

While community and media attention has recently focused on alleged inappropriate discharges of homeless patients in large metropolitan areas,
the challenges presented by this patient population are almost universally unacknowledged outside of the hospital community. Inappropriate
discharge of any patient is always a cause for concern. Communities and the patients who live in them will benefit if the people involved in the
care and protection of the homeless collaborate to focus on solving the challenges rather than accusations of blame – the Interim Care Project
(ICP) in Sacramento, CA, is evidence of this.

In 2003, several social service organizations in Sacramento expressed homeless patient has needs that extend beyond his or her acute
concern to local hospitals that homeless patients were being discharged medical needs.
back to the streets before it was medically appropriate to do so. While The group’s vision, developed as the specific needs of post-discharge
these concerns did not play out in the pages of the newspapers or the care were discussed, is to offer a safe place capable of providing:
evening news, the local hospitals were invited to a meeting to defend • 24-hour respite shelter
themselves. In fact, local hospitals were keeping medically at-risk
homeless patients in the hospital beyond normal discharge in order to • Necessary daily services
provide them with what would have been outpatient care if they were – Three daily meals
not homeless. The meeting began a productive discussion that led to an – Housekeeping and laundry
even more productive and valuable collaboration that continues today. – ADA standard bathrooms
• Case Management services
THE INTERIM CARE COLLABORATIVE – Provide access to ongoing health care through community
The group that initially met to discuss the challenges of caring for health clinics
and safely discharging the local homeless population quickly – Provide access to needed social services support through
recognized that collaboration was the only way to bring together the community-based services.
necessary expertise, resources and commitment to extend the
continuum of care for these vulnerable patients. The Interim Care PROGRAM DEVELOPMENT AND DESIGN
Collaborative began – including Sutter Medical Center, University of One of the first steps in the project’s development was to identify a
California-Davis Medical Center, Mercy Hospitals, Kaiser Permanente, profile of the patients who could be served. A screening tool was then
the County of Sacramento’s Department of Health and Human Services developed from the profile so that patients can be appropriately
and Department of Human Assistance, the Salvation Army shelter, and identified by any participating hospital. Patients need to meet all
a community health center clinic (The Effort). Representatives from the standard hospital discharge screening criteria: be medically stable for
participating organizations were manager-level employees who had discharge, alert and oriented, independently mobile (including use of
the authority to commit resources.
A primary objective of this
group is to utilize and expand
existing services and
organizations, not to create
something new. The shared goals
of the group include:
1. Provide short-term housing
for homeless patients
post-discharge from the acute
care setting,
2. Provide a stable environment
that links medically at-risk
adults to community-based
social services,
3. Establish eligibility for
public assistance and health
FIGURE A
care coverage,
assistive devices) and have a short-term need for respite housing of no
4. Facilitate the transition of homeless at-risk adults to permanent more than 6-weeks. The six-week period is based on a typical course of
housing and employment. IV antibiotic treatment, which was the most common need for this
These shared goals embrace the idea of addressing the needs of the respite housing solution. Further, for a community-based solution to
whole person, recognizing that, no different from any patient, a work, all patients must be appropriately cared for by non-medical
continued on page 6
5
 C O L L A B O R A T I V E
Community Collaboration – The Interim Care Project in Sacramento, CA (continued from page 5)
personnel and be willing to abide by all shelter behavior requirements.
Transportation with bus voucher is arranged for patients who require
periodic physician or ancillary service appointments during this time.
Once a patient profile was agreed upon, the process was diagramed
so that the group understands all the steps and processes that need to be
in place for an effective solution. That process flow is shown in Figure A.
The next step was to identify a budget and, importantly, the
collaborative partners’ roles and responsibilities. The roles and
responsibilities align with the participating organizations’ skills
and strengths. The community health clinic has the administrative
capabilities to provide program administration as well as health clinic
services for follow-up primary care coverage and medical management
of the patients.
The Salvation Army shelter has the infrastructure, available space
and management of a 24-hour unit that, with remodeling, became an
appropriate setting for these patients, segregated both by gender and
from the regular homeless shelter that operates in the evenings from
dinner-time until breakfast the next morning. A total capacity of 18
beds was created; resources were put in place to offer the addition of a
lunch meal to the patients and staffing put in place to accommodate
people in this part of the shelter during daytime hours.
The participating hospitals provide not only the donations of beds
and other necessary equipment, they also commit annual funding of
$50,000 per hospital, to coordinate the discharge services, to
participate on clinical review committees and to fund durable medical
equipment and prescriptions as needed.
The County of Sacramento provides oversight of all community
shelters, and therefore gained oversight of this respite shelter as well. The
County also provides funding to support the program. A typical bed in a
homeless shelter in Sacramento costs about $14 per day to operate.
County budget and Federal dollars provide the budget to expand the
shelter by 18 beds. The participating hospitals’ contributions supplement
the additional cost to keep these 18 shelter beds open 24/7. The County
also provides an onsite eligibility worker to determine eligibility of
patients for Medicaid or other state programs for the medically indigent.
Case management services for all eligible clients are also provided.
The clinical review committee provides ongoing monitoring and
measurement of the outcomes. Staffed by hospital case managers,
county eligibility workers, nurses from The Effort and representatives
from the Salvation Army, this group does regular case reviews to assure
that protocols and criteria are met and to identify and exploit any
opportunities for performance improvement. Frequently, this oversight
includes troubleshooting barriers to admission, such as out-of-county
residents, patient mobility problems, active substance abuse by a
patient, patient dependency for self-care and no-shows.
There is also an Oversight Board comprised of one voting member
from each partner agency. Responsible for overall program oversight,
this board reviews protocols, troubleshoots problems and develops/
approves the annual budget.
OUTCOMES
The respite shelter solution is working well for homeless patients in
Sacramento, and the 18 beds are frequently full. There are now
appropriate services in place to care for a unique segment of the
C A S E M A N A G E M E N T
homeless population in Sacramento County. Knowledge of the
program was almost immediate – the partnering social service
agencies and staff are excellent at matching people with needed
services, and patients themselves spread the word among their peers.
In fact, abuse of the program is something that hospital and social
service staff must guard against. Some patients view the respite shelter
as a potential opportunity for a 24-hour shelter without the daily wait
in line at dinnertime. Vigilance with the screening tools has kept abuse
of the program to a bare minimum.
Since the inception of the ICP program in 2005, 54 patients from
Sutter have been served – resulting in approximately 1,300 saved
hospital bed days. Other measured outcomes also demonstrate success
from the perspective of the partner hospitals. For example, during the
first quarter of 2007:
• While 22% of patients had no insurance, but by the time they
exited the program 0% were without any coverage. The Effort
ensures that clients enroll in Medi-Cal, CMISP, or other coverage
for which they may be eligible.
• All participants are offered mental health and substance abuse
services while in the program.
• 81% of participants move from the ICP into some type of housing
(permanent supportive housing, transitional housing, shelter,
board & care, etc.)
• Just 18% of clients require a visit to the emergency department
during their stay.
• 75% of clients use a primary care clinic for treatment during
their stay.
• Only 8% of patients were re-admitted to the hospital.
• The average length of stay at the ICP is 24 days.
WHAT THE FUTURE HOLDS
Perhaps the most valuable outcome of the Interim Care Program
lies in the successful community collaboration. The bridges of
trust and a common language that have been built are strong, and
success breeds enthusiasm for new challenges. Partners are now
working on several new, more comprehensive programs to support
other niches of under-served patients in the community. Among
those projects are:
• An interim housing solution for homeless patients who are not able
to be completely independent (who likely rely on friends when living
on the street) and need home support services delivered to them on
a daily basis or assistance with medications.
• A program to reduce the use of hospital EDs for primary care among
homeless patients. Under development is a capitated funding
mechanism that would provide the necessary financial support to
The Effort health center so they can manage a group of patients.
Kate Tenney
Tenney, RN, has been Manager of Case Management at Sutter
General Hospital in Sacramento, CA for seven years. Previously she
served as Utilization Manager for Managed Care for Lovelace Health
System and Cardiac & Renal Transplant Coordinator for Presbyterian
Health Service, both in Albuquerque, NM. She earned her AS in Nursing
from Hartnell College in Salinas, CA.