The RISE Association’s webinar series recently featured a case study on a community-based, multi-hospital system medical respite program in Pittsburgh, Pa. that aims to provide care to people experiencing homelessness.

The RISE Association recently sponsored its first webinar exclusively earmarked for  its social determinants of health (SDoH) community. RISE was joined by speakers from Bethlehem Haven and Pittsburgh Mercy, who shared an inside look at their partnership in the development of a medical respite program to provide individuals experiencing homelessness with a safe and healing place to recover from a physical illness or injury that is not serious enough for hospital care. The medical respite provides individuals with the home care they need but would not otherwise receive once discharged from a hospital. The program also provides SDoH screenings.

Here are three key takeaways the presenters shared during the webinar:

1. Partnership between community health systems strengthen the impact of a medical respite program.

Collaboration between community-based health systems can significantly impact the influence and outreach of medical respite. Through its partnerships with surrounding health systems, Bethlehem Haven (BH) established the first medical respite facility in its region. The Pittsburgh medical respite pilot program was created in 2016 in partnership with Allegheny Health Network (AHN) and Community Human Services (CHS).

The collaborating health systems contributed to the pilot in different ways to build the comprehensive care model they strived for, explained Sharon Higginbothan, Ph.D., chief operating officer, Bethlehem Haven:

  • BH and CHS housed five beds each for the program
  • AHN provided the team with a registered nurse, certified registered nurse practitioner, and social worker
  • BH provided the respite care coordinator
  • Pittsburgh Mercy provided a mobile medical unit and psychiatric consults.

The program continued to evolve over the course of two years and gained two new partners, UPMC and UPMC Health Plan. The program moved to a state-of-the-art facility, expanded the respite team, and transitioned all onsite care to Pittsburgh Mercy.

2. Medical respites look different across the board.

There is no cookie-cutter approach to medical respite, noted Higginbothan.

For example, a unique feature of the Pittsburgh medical respite program is its referral process, which is ever evolving to meet the needs of the population, said Matthew Cotter, MSW, senior manager, Pittsburgh Mercy. Referrals are made in different ways, with AHN partners using their own respite consult team and filtering referrals through their hospital system, and UPMC partners sending referrals to the Pittsburgh Mercy respite team. “Regardless of where the person comes from, the care they receive at the respite is always the same,” said Cotter.

Care models within a medical respite will vary, too. Some of the features at Pittsburgh medical respite include, but are not limited to, daily huddles to update staff on client statuses; stakeholder meetings to provide progress updates, needed changes, and receive feedback; weekly community meetings with clients; and an after-care program to provide clients with continued support after respite.

Due to the COVID-19 pandemic, the medical respite program had to quickly pivot its care model. The team converted three of the 29 rooms to quarantine rooms, modified the ventilation system to ensure proper air flow, updated quarantine bathrooms, and increased the frequency of cleaning.. Testing strategies and care management adjustments were also made for proper screening procedures.

3. Utilization patterns and data statistics provide foresight for continued evolution.

The Pittsburgh medical respite team continues to evaluate the evolution of their program, and the data statistics they collect offer a close look at the different strengths and areas of opportunities within the program.

An encouraging sign of the program’s impact, noted Cotter, is the data collected on disposition from medical respite. Based on their data collected since the expansion of the program up until the end of May 2020, the most popular disposition from medical respite is permanent housing. “I can’t stress how incredible that is, and it’s such a testament to the care coordination, housing coordinator, and the model at respite,” said Cotter. Some of the areas the medical respite plans to focus additional attention on based on the data statistics include money management and health management, he said.

Looking ahead

The Bethlehem Haven medical respite model will continue to evolve based on the fluid environment and response to the model, explained Annette Fetchko, R.N., MHA, executive director, Bethlehem Haven.

Based on the influx of positive responses so far, Fetchko said the medical respite is in the process of taking a close look at how to best continue to respect and maintain the integrity of current stakeholders and what other potential community partners may be interested in when it comes to a medical respite partnership. To better understand this, the medical respite is currently working with CACHE consultants to evaluate different areas of information including resident surveys, conversations with current stakeholders, and outreach to local and regional stakeholders to hear their perspectives on medical respite.

Another key focus area for the medical respite: continued SDoH screening, said Fetchko. The medical respite aims to continue to better understand the social influences that impact the abilities of individuals across the system of care and how to best assess and capture SDoH across the populations the medical respite serves.

The RISE Association will sponsor another webinar in partnership with FOX for the SDoH community on geriatric house calls, 1:30 p.m. EST., Thursday, Oct. 1. Webinars are free to members of the RISE Association. To learn more about the association and its communities, click here.