Post-Acute Care For Unsheltered Community Members



An individual’s health is strongly affected by resources and supports that exist in their surroundings. The absence or presence of shelter and food in a person’s environment can forecast success or failure in recovery from an acute illness. This reality prompted Providence Regional Medical Center Everett (PRMCE) to partner with Everett Gospel Mission (EGM) to provide medical respite shelter beds for unhoused community members following an acute care hospital stay.

Like many hospitals across the country, PRMCE cares for numerous community members who are living outside without shelter, sanitary conditions or access to healthy nutrition—all detriments to healing from acute illness. Often, an unsheltered patient no longer needs acute care but is unable to access necessary post-acute care services because of their housing circumstance. Skilled nursing facilities will rarely accept a patient who is not housed, and home health agencies cannot care for people without an address.

This dilemma caused the hospital to seek innovative ways to support the unsheltered population in a healthy recovery. The PRMCE CEO reached out to EGM, and a partnership was formed for a medical respite shelter. EGM offered to reconfigure an unused area of their current men’s shelter to make eight medical respite beds. A further 16 beds at the women’s shelter were designated for respite use. Initial financial support came from a capitol campaign headed by EGM CEO Sylvia Anderson. PRMCE provided an initial donation, but ongoing financial support is provided by donors that support Everett Gospel Mission.

Providence Medical Group offered to provide a nurse practitioner to oversee the medical care of the respite residents. The Washington State Department of Health was apprised of the project and gave their blessing. Providence Home Health joined the partnership, providing skilled physical therapy (PT), occupational therapy (OT), speech therapy, and registered nurses to care for the EGM medical respite residents under home health guidelines.

EGM CEO Sylvia Anderson reports that after a few meetings with PRMCE, a memorandum of understanding was written on what the partnership involved for each party. She states that it took several attempts to get the factors identified and adjusted to make the medical respite shelter work as well as it does today.

The process of transitioning a patient from the hospital to the EGM medical respite shelter begins when the inpatient case manager identifies a candidate who is living unsheltered and has a post-acute medical need. A person with a wound on a lower extremity who is recovering from an infected abscess, needing dressing changes and requiring physical therapy due to prolonged hospitalization and debility is an ideal candidate. Another suitable person might be a CHF patient who needs the home health RN to help with medical management of new cardiac medications, as well as PT and OT for mobility and activities of daily living.

When a possible medical respite shelter patient is identified, the next step is to determine if the patient wants to participate in the EGM medical respite program and will agree to the rules. No illegal drugs or alcohol are allowed on the property. The candidate must be able to manage their own hygiene, as caregiving is not provided. Navigating the facility independently to obtain premade meals from the kitchen is also required. Residents must turn in all medications to the shelter staff and agree to take them as prescribed. Medical respite shelter candidates will have their prescriptions filled at the hospital before they discharge, and they must be able to load the medications into a weekly Mediset for medication management. They may get assistance from an outpatient case manager for medication packing if needed.

Additionally, it is mandatory for medical respite shelter residents to meet as necessary with the Providence medical team members and to follow their instructions for care. A release of information form is signed by the prospective resident to obtain information from outpatient mental health providers, and the provider must confirm that the candidate is appropriate for the medical respite program. Before leaving the hospital, all prospective medical respite shelter residents must be cleared from risk of active drug or alcohol withdrawal. Transportation from the hospital is coordinated by EGM via their van. The respite stay is not expected to be longer than 30 days.

During their stay, EGM will provide residents of the program with a safe place to recover after their hospital admission. EGM provides laundry and kitchen facilities, with lunch and dinner provided Monday through Friday. Each person is given a 27-gallon storage bin for their personal items. EGM has its own case managers who are available to assist medical respite residents and, upon request, can facilitate a resident’s move to the shelter’s general population after their time in respite has ended.

EGM medical respite can accept patients on oxygen, those with a sealed wound vacuum, wheelchair users who are able to operate a cargo elevator and those who are registered sex offenders that are level 1 or 2. Smokers are welcome but must smoke only in the designated area. Those on a methadone program are accepted if they have take-home privileges from the methadone clinic. The medical respite program cannot accept hospice patients. The cots have a 350-pound maximum weight limit, so those over this weight must be able to get up under their own power from a mat on the floor.

Many of the respite residents are motivated to do their part, get better and move to the next step of obtaining permanent housing. Providence Home Health and EGM have agreed that the home health clinician will come and admit the EGM medical respite resident the day after they arrive between 11 a.m. and 12 p.m. During that visit, the home health clinicians set up subsequent visits, which are confirmed the morning of the scheduled date. Because the medical respite residents often do not have their own phone, it can be challenging for the home health clinicians to connect. In this instance, EGM staff will accept calls and relay information to the resident.

The medical respite shelter program has been operational for less than two years, and during the peak of COVID, admissions were not allowed. Forty-nine men have transitioned from acute care to medical respite, as well as several women. Unfortunately, not everyone stays in the medical respite program until they no longer have health needs. Some choose to leave before the medical team would like, returning to living outdoors. There have been quite a few success stories, however.

Sylvia Anderson reports that many of the medical respite shelter residents have gone on to get permanent housing, Supplemental Security Income, and stable work. Eighty percent of the medical respite shelter residents have transitioned into the general shelter population once their medical issue was resolved. EGM case managers provide and refer for all types of services—from immigration, legal issues and evictions to medical and mental health referrals. They also provide personal and spiritual support.

The Everett Herald newspaper featured a story of a patient who transitioned from acute care to the EGM medical respite shelter. He has Type 1 diabetes and challenges with substance abuse. He had been robbed and beaten, and because of his poorly controlled insulin-dependent diabetes, his wounds were not healing. He had been in and out of the hospital multiple times. With the clean, warm environment of the EGM medical respite program, he was able to heal. He engaged the case manager at EGM and moved into their Passport Program, working toward self-sufficiency and eventually began to help run EGM, working at the front desk.

It is heart-wrenching for acute care case managers to discharge an unsheltered person with ongoing medical needs to the street. All of us who work in acute care have been in this position; knowing that our patient will fail managing their health conditions living outside yet having no post-acute options available. Through caring collaboration, Providence Regional Medical Center Everett and Everett Gospel Mission have created a valuable partnership to provide much needed post-acute care in a warm, safe environment for unsheltered community members.

gayle alkire

Gayle Alkire, MSN, RN, CRRN, CCMworks as a nurse case manager for Providence Regional Medical Center Everett. She has a master’s degree in nursing and a nurse educator certificate. She is certified in rehabilitation registered nursing and case management. She has a passion for serving vulnerable members of the community and volunteers for the street medicine organization Mercy Watch.


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