Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another.

The problem

Healthcare for homeless individuals can be challenging: Untreated substance use and mental health issues are common, and social supports are either lacking or not coordinated cohesively.

“Many of these individuals haven't had positive experiences with healthcare or don't know how to navigate their benefits," says Jodi Nerell, director of behavioral health integration at Sacramento Covered, a community-based nonprofit in Sacramento, California, that connects residents to healthcare.

Sacramento County has resources, Nerell explains, but they're not particularly well-aligned with clients' needs. “We're resource-rich, but the deck isn't set up in a way to customize those resources."

Specifically, Sacramento is one of just two counties in California with a complex geographic managed care (GMC) system, which requires recipients to choose one of five plans and then a health clinic. Behavioral health services are split, with mild to moderate acuity treated within the community clinic network, and acute psychiatric/addiction care accessed through the county system.

The result is a labyrinthine system that's difficult for patients to navigate. “The existing system is set up for [people] to fail," Nerell says.

The solution

California released the Whole Person Care initiative to address these gaps in 2017. It's opt-in, and 25 counties have chosen to participate so far. There are 22 other states that have similar programs, but California's is particularly robust.

Sacramento became the only city in the state to enroll in the program when its county opted out. The city named its local version of Whole Person Care “Pathways to Health + Home" to create a sense of ownership and show the focus of its particular program. It aims to provide semi-permanent to permanent housing to 2,000 homeless individuals by 2020 through a more coordinated, responsive, and sustainable system.

Nerell, using her existing expertise with Sacramento Covered, helped define and direct the city's initiative; Sacramento Covered has now been contracted with the city to spearhead these efforts.

It can now receive referrals directly and immediately from hospitals, health clinics, and city services for homeless individuals without healthcare coverage, with enrollment based on the city's established utilization criteria to quickly identify those who qualify.

Sacramento Covered's paraprofessional health workers in the field also connect directly with enrollees. “We develop a shared-care plan that is person-centered and extrapolates goals with the enrollee: What do they want to start with? Health? Housing? Social Security? Disability? We address all of the above," says Nerell.

Health data from that intake meeting become the basis of a shared electronic care plan that will update across medical record and provide alerts when an enrollee is hospitalized.

Of Sacramento's seven federally qualified health centers, three are contracted with Pathways, which means that enrollees get direct, expedited access to their services — like appointments, pharmacy, and refills — and facilitated recuperation from surgery. And Sacramento Covered works with the Social Security Administration to help expedite enrollees' movement through the system.

A winter triage shelter opened last year has been extended through August, and Sacramento is researching tent-like “sprung structures" that can house hundreds of homeless individuals. The city is working to add recuperative/respite beds for surgery recovery — currently there are only 34.

The outcome

Though Sacramento joined the program later than some counties, its numbers and participation are strong.

Sacramento Covered has worked with 1,028 recipients since November 2017. Currently, 587 are enrolled – often, participants either disenroll because they obtain other benefits or are graduated because they demonstrate that they can self-manage. Over half of the enrollees are 55 or older — increases in the aging population and current affordable housing shortages will likely mean more homeless seniors.

“We've seen drops in hospital utilization and increased visits to primary and specialty care appointments as a result of our work," says Nerell. “Thanks to these efforts, we're aiming to help people get back on their feet and not overburden the healthcare system. Ultimately, assisting these suffering, underserved individuals is our end-goal."

“What we've been able to demonstrate is that a small, highly trained teams, with big hearts and shared mission, can help remove seemingly intractable obstacles," Nerell adds.

Katherine J. Igoe is a frequent contributor to athenaInsight.