Central City Concern's Recuperative Care Program: Transforming the hospital discharge for patients facing homelessness

Hospitals and major medical providers are faced with serving patients who are ready for discharge, but are held unnecessarily or return immediately to the emergency department because of social barriers, lack of primary care/insurance and homelessness. Through an innovative partnership started in 2005, Portland, OR area hospitals refer eligible patients to the Recuperative Care Program, paying for housing and direct services provision for socially complex and medically vulnerable homeless adults and produce net savings for participating hospitals via reductions in uncompensated care. These patients are often in need of social service assistance, behavioral health and substance abuse recovery and specialized housing placement. Central City Concern's Recuperative Care Program creates connections for hospitals, HMO's and health agencies to immediate housing, specialized and intensive case management and a primary care home with immediate post-hospital follow up for their most vulnerable patients. Patients are picked up from the hospital (not dropped off on the shelter steps), given their own room, and are immediately established with a primary care doctor and a multi-disciplinary case management team, transforming the patients experience of their health care, lowering the costs for the population and most importantly, improving clinical outcomes.