For people with severe mental illness, substance abuse problems, or other disabilities, who do not have a place to live upon discharge from a hospital, jail, or foster care setting, planning for needed housing, treatment, and support services prior to discharge is critically important. Discharge planning efforts often utilize a team or collaborative approach that includes a comprehensive assessment of each individuals needs in advance of the time of discharge, an assessment of housing needs and identification of multiple options, arrangement for follow-up appointments and medications, the engagement and active involvement of the homeless individual in identifying needs and preferences and considering options, a plan that delineates clear responsibilities, and back-up or contingency plans. However, discharge planning has no teeth unless the needed housing and services are available in the community (Semansky et al., 2004), and successful discharge planning is contingent upon effective linkages to community housing and services that are available and accessible at the right time (Moran et al., 2005). For some chronically homeless people, the time of discharge offers an important opportunity for engagement, enhancing motivation to change behaviors or circumstances that led to a health crisis or institutionalization, and establishing linkages to housing and ongoing care in the community that can help sustain recovery. Critical Time Intervention (CTI) (Herman et al., in press) discussed previously, is currently being studied in the transition from jail and state hospital settings to the community; findings are not yet available.
Respite or recuperative care is a promising approach to meeting the needs of chronically homeless people at the time of discharge from hospital or other health care facilities. For patients who are not homeless, our nations health care delivery system has undergone significant changes in recent years. Increasingly surgery and other medical procedures may be performed on an outpatient basis, and hospital stays are shortened for all types of health care. Patients are frequently discharged from the hospital in need of home-based rest and care (from family members or visiting health care providers) and compliance with complex instructions for wound care, medications, or post-surgery rehabilitation. Homeless patients are particularly vulnerable when discharged from hospitals after emergency or inpatient care, including surgery. A growing number of communities have established respite or recuperative care programs as an alternative to costly extended hospitalizations or discharging patients to the streets or shelters or a short-term stay in a motel room.
Respite or recuperative care programs serve homeless people who do not need to be hospitalized or in a nursing home, but are too ill to be on the streets or in shelters. Programs operate in a range of settings, including free-standing facilities, specialized shelters or transitional housing programs, and beds or units set aside in emergency or transitional housing programs with additional staffing and adaptations to requirements as needed For example, other shelter residents may be required to leave the facility during the day but those occupying respite beds may remain in the facility if they need bed rest. Generally these programs offer short-term housing (a few days or a few weeks) where participants can stay 24 hours a day as needed and receive meals and help with mobility and self-care. Some health care services are provided on site by nurses, a physician or mid-level practitioner, or other health care providers, but these services may be intermittent; for example, nurses may visit several times a day and be on call for emergencies, but limited health care staff are on site during much of the day. Programs also generally offer a range of supportive services and assistance with transportation to medical appointments, while seeking to facilitate long-term housing placements for clients.
One study of the effects of respite care (Buchanan et al., 2006) found a 49 percent reduction in hospital admissions among patients who received respite care, compared to similar patients who received usual care, after adjusting for gender, race, age, diagnosis, and previous utilization of health services. The average cost of respite per hospital day avoided was $706, approximately half the estimated cost of a day of hospital care.