The People Concern’s Health and Wellness Program (HWP) was developed in 2017 in partnership with six hospitals: Providence St. John’s, UCLA Santa Monica, UCLA Ronald Raegan, Kaiser West LA, Cedars Sinai and Cedars Sinai Marina Del Rey Hospital (MDRH). The program focuses on connecting high utilizers, defined as an individual who visits a hospital at least three times within a three month time period, to supportive services while reducing unnecessary visits to hospitals. “Our goal is to find out why these individuals are high utilizers. Is it because they want a meal or a safe place to rest at night? Do they have a medical problem but don’t know how to access primary healthcare? Do they have a medical problem that is so severe that they have to go to the Emergency Department (ED)? We answer these questions by engaging with participants and building trusting relationships to determine what their unique needs are and then, we work together to meet those needs.” says Marrisa Axelrod, the Director of Community Nursing for The People Concern.

The HWP is comprised of three programs that operate as a collaborative team to solve the issues of high utilization of the healthcare system: Wellness Connection, the Hospital Liaison Program and the Community Navigator Program.

  1. Wellness Connection is specifically designed to reduce emergency department overutilization among people experiencing homelessness by connecting them to comprehensive supportive services including primary healthcare, mental health services, harm reduction services, interim housing and permanent housing. Staff meet people where they are and coordinate services and care for the most hard-to-reach individuals by providing them with Registered Nurse support and Case Management services.
  2. The Hospital Liaison Program acts as a filter for Social Workers, Case Managers and Patient Navigators providing on-call support to hospital staff and helping hospitals build capacity for working with unhoused patients. The Hospital Liaison reconnects patients who are experiencing homelessness to services and resources through the Coordinated Entry System (CES) and works directly with patients to provide resources specific to that person’s immediate needs.
  3. The Community Navigator Program was first implemented at MDRH Emergency Department. The Navigator role is largely responsible for assessing patients who are experiencing homelessness, particularly those who utilize the emergency room for basic needs, and triaging them to community-based resources. This endeavor manifests in a myriad of ways but usually involves an effort to increase accessibility for resources to fulfill patients’ basic needs like housing, food and support for mental health and substance abuse. The program also connects high utilizers of the ER who are experiencing homelessness to appropriate medical services as well as supportive non-medical services tailored to the unique needs of the individual.

Since its inception, The People Concern’s Health and Wellness program has seen significant positive results. We have seen a reduction in overutilization at all partnering hospitals. Of 174 people served by the program, 63% of patients have received a referral to a medical home, 32% were linked to mental health care, 35% were linked to interim housing and 15% entered into permanent housing.

Our work allows us to reduce overutilization and improve the quality of life for program participants like David. David visited the ER weekly to obtain ostomy supplies because he did not have health insurance. He was living unsheltered and could not have the supplies sent to him; the supplies he had would often get stolen or lost. The HWP team connected with David and began delivering supplies to him in the field. Through HWP, David was also linked to primary healthcare and ultimately, to permanent housing. From the time our team started working with him to the time he was housed, he never once went back to the ED! “A key component of HWP is building trust. We don’t give up on people. They may give up, but we will continue to be there. Many people experiencing homelessness have a long history of being let down by people and systems. Our team shows up for our participants no matter what. We go the extra mile and they see that,” shares Marrisa.

Our Health & Wellness Programs are life-changing for patients like Chris. Chris was living on the streets and desperately needed eye surgery; he had mostly lost his vision and was visiting the emergency department every day because he could not navigate his world and needed a safe place to stay. Our team connected with Chris and referred him to the services he needed. After receiving four eye surgeries, Chris has his vision back, is housed and successfully living in his apartment!

The Health and Wellness Program is another example of The People Concern’s dedication to bringing innovative solutions to address challenges in our community. We are proud of the success we have had thus far and look forward to continuing this vital work.