Background: Patients experiencing unsheltered homelessness are at extreme risk for worse outcomes, including increased mortality 10 times that of the general population and an average life expectancy of 53 (over 20 yrs less than general population). Transitions of care pose unique difficulties for this vulnerable population, with numerous barriers to ongoing care and resulting readmission rates up to 2.5 times those for housed patients.Clinicians may feel a degree of futility caring for patients experiencing unsheltered homelessness, leading to frustrations for patients and care teams, as well as suboptimal care during hospitalization and after discharge.

Purpose: We designed a novel pilot care model to improve transitions of care for patients experiencing unsheltered homelessness during hospitalization, on discharge, and for 30 days after hospitalization.

Description: Our pilot care model connects patients experiencing unsheltered homelessness with specialized outpatient providers/clinics experienced in caring for this population,as well as dedicated community health workers, social workers, and resources to help facilitate improved transitions of care.The design team consists of physicians, community health workers, providers from our local Street Medicine and Healthcare for the Homeless medical teams, social workers, and medical students.The model consists of 5 elements:1) A member of our core team actively communicates with internal medicine wards teams at our local academic, safety net hospital, to identify patients experiencing unsheltered homelessness who also experience significant medical complexity and recent hospitalizations and/or readmissions in the prior 6 months.2) We mobilize a community health worker to meet with the patient early during their admission to actively explore barriers to ongoing care and a comprehensive checklist of social determinants of health.3) Screened patients are added to a case list, which is reviewed during a semi-weekly case conference that aims to create a human-centered care plan for each patient. Goals include providing connection to appropriately specialized outpatient clinics (eg Healthcare for the Homeless Clinic) as well as resources and social service providers to assist with food instability, medication/prescription costs, lack of housing, and financial instability.4) Our community health worker meets with the patient after discharge, assessing continued needs and how well the current care plan has been working over the 30 days after discharge.5) Care plans are adjusted during case conferences and shared with the core team.We are currently gathering data on length of stay, readmission rates, outpatient follow-up, mortality, costs of care, and patient experience.

Conclusions: We anticipate that this intensive, multi-disciplinary approach will allow our patients experiencing unsheltered homelessness to achieve improved followup appointment adherence, medication adherence, trust in care providers, readmissions, and lengths of stay.