SHM Converge Scientific Abstract ePoster Gallery-Intervention to Enhance Post-Hospital Care for Patients Experiencing Unsheltered Homelessness

Pdf Summary

This project describes a pilot intervention called CATCHH designed to improve transitions of care for patients experiencing unsheltered homelessness after hospitalization. The need is urgent: unsheltered homelessness is associated with severe health risks, mistrust of health systems, major barriers to follow-up care, and readmission rates about 2.5 times higher than those of housed patients.<br /><br />The program aims to strengthen discharge planning and post-hospital support by involving a community health worker (CHW) early during admission. The workflow includes referral from the inpatient medicine team, an initial encounter with the patient, collaborative care planning with social workers and clinicians, discharge coordination, and handoff to community and outpatient resources such as street medicine and healthcare-for-the-homeless teams. The model emphasizes patient-centered care, early engagement, knowing where patients can be reached, clear communication with inpatient teams, and starting with a small caseload to avoid duplication and confusion.<br /><br />Early lessons from implementation show that focusing on each patient’s priorities helps build trust and improve follow-up. Early inpatient visits support better planning and stronger relationships. Consistent contact depends on understanding where patients are likely to be found. Clear expectations for inpatient teams and case managers are important to prevent overlap. The team also found that reducing caseload early on was necessary for effective coordination across multiple organizations.<br /><br />Since launching in January 2023, seven patients have enrolled. Initial outcomes suggest improved trust in hospital and care management staff, greater patient engagement and communication, and better 30-day follow-up with primary and specialty care. Mortality, length of stay, and readmission outcomes are still pending. An outpatient provider noted that the CHW helped ease the transition to medical respite and maintained post-discharge support, especially with insurance and long-term planning.

Asset Subtitle

James M. Hubley

Meta Tag

Author List James M. Hubley, Matthew Hunt, Read G. Pierce, Richard Johnson, Sanjana Ravi, Tim Mercer

Category Innovations

Concept Unsheltered homelessness

Concept CATCHH Care Model

Concept Hospital Discharge

Concept Continuity of Care

Concept Community Health Worker

Distinguished Finalist

Presenter Organization Dell Medical School at University of Texas at Austin

Presenting Author James M. Hubley

Track Transitions of Care

Keywords

unsheltered homelessness

hospital discharge planning

care transitions

community health worker

post-hospital support

patient-centered care

readmission reduction

street medicine

healthcare for the homeless

care coordination

Unsheltered homelessness

CATCHH Care Model

Hospital Discharge

Continuity of Care

Community Health Worker