Recuperative Care Program

“Too well for the hospital, too sick for the street.”

Our Recuperative Care Program (RCP) provides care to homeless clients who may no longer need a hospital setting but still need skilled nursing care, and are not safe to be discharged to the streets. In a nursing home setting providing medical care, RCP provides program coordination, intensive case management, weekly drug/alcohol/mental health counseling and eventually, a pathway to housing. Utilizing the Health Care for the Homeless practice model, Front Steps assists clients by facilitating access to primary medical care, social services, behavioral health, addiction services, vision and dental benefits. RCP ensures that patients receive education regarding chronic disease management and post-discharge self-care which includes the identification of a primary care clinic for ongoing health care needs. Ideally, clients move into permanent or transitional housing following program completion, with ongoing intensive case management support to assist them in maintaining housing and maintaining their health. Despite long periods of homelessness and lack of involvement with social services prior to entering RCP, clients have demonstrated great success in achieving goals, such as obtaining government disability benefits, becoming clean and sober, re-establishing contact with family and even returning to school or work.

In the last Fiscal Year:

RCP provided 2990 occupied bed days to 79 individual clients.

85% of the clients were able to establish primary physician services with Community Care clinics. Many of these clients were also connected to Integral Care to assist with their mental health needs.

Reasons for admission into RCP included: assistance with medication management (1%), wound care (24%), intravenous antibiotics necessary (18%), and therapy services were required (57%).

Among individuals leaving RCP: 16 went to live with family/friends, 23 returned to the streets/camp, 9 went into a shelter, 3 went to a boarding home, 7 resided in Front Steps permanent supportive housing after discharge, 6 returned to the hospital, 4 went into long term care after securing disability benefits with staff assistance, and 2 passed away.

 

Recuperative Care Reduces Future Hospitalizations

Research indicates that individuals experiencing homelessness stay 4.5 days longer in hospitals than non-homeless people and they are 10 times as likely to present to the ER than a low income individual with stable housing. A study published in the American Journal of Public Health revealed that recuperative care after hospital discharge reduces homeless patients’ future hospitalizations (3.7 vs. 8.3 days). An article in the Journal of the AMA reports that housing and case management provided to a population of homeless adults with chronic medical illnesses results in fewer hospital days and emergency department visits compared with usual care.

Recuperative Care Success: Dwayne’s Story

Dwayne came into Recuperative Care for the first time following a lengthy hospital stay in which he was admitted for altered mental status and other co-morbidities that had been left untreated due to living on the streets. Dwayne came to RCP a second time when he was admitted to the hospital due to liver failure. Dwayne was in bad shape as he actually had died at the hospital and had to be resuscitated.

Dwayne came to RCP at Heritage Park unable to walk and he had difficulty talking. He was easily confused. He was told by the doctors his prognosis was not good, especially if he decided to drink again. During his time at RCP he received physical therapy, occupational therapy, and speech therapy. He also received assistance for his chemical dependency.

While Dwayne was participating in therapies provided by Heritage Park, RCP case managers helped him apply for Social Security benefits. He was also able to obtain a birth certificate,Texas ID, and Social Security card. After a few months Dwayne was approved for Social Security benefits. For his health and safety, Dwayne decided it would be in his best interests to stay in the facility for long term care. Shortly after he completed his therapy he switched over to be a resident at Heritage Park.

Dwayne now lives at Heritage Park Nursing Facility as a long term care resident. He is walking and in much better health. We were also able to help connect him to his sister who lives in Dallas and she visits him once a month. David is appreciative of the assistance that RCP provided to him during both his stays. He is a story of success, his health and well being have improved and he drops into the RCP office every now and then to check in and show off how great he is doing!

“I am so thankful that I was able to come to recuperative care. I was able to heal after my operations. Now I am working on finding a house.”

Marvin, Tejas House resident