New Directions is a program led by the Hospital Council of Northern and Central California, working to serve people who are the most frequent users of hospital emergency room services in Santa Clara County. A multi-disciplinary team partners with four hospitals to identify and engage people who have frequent and avoidable hospital emergency room visits. In addition, the contracted hospitals may refer patients who are receiving inpatient care who are at risk for future hospitalizations due to their living situations in the community. Many of those who have frequent and avoidable visits to hospital emergency rooms are experiencing homelessness or unstable housing and they often have complex health problems that may include co-occurring mental health, substance use, and chronic medical conditions. The New Directions team provides case management, care coordination, and linkages to housing and other services. The program also provides services to patients of the County’s medical respite program. Services are connected to permanent supportive housing opportunities including Shelter Plus Care vouchers and Housing Choice Vouchers provided through a partnership with the local public housing authority.
Problem or Challenge:
A small number of patients frequently visit hospital emergency rooms where care is extremely expensive. Their hospital visits account for a disproportionate share of costs for hospitals and contribute to overcrowding and stress for patients and staff in emergency departments. Hospital emergency rooms are not the best place to respond to the needs of these patients who are often experiencing homelessness and have complex, chronic medical conditions complicated by co-occurring mental health and substance use problems. More appropriate health care and supportive services could reduce avoidable emergency room visits, but without stable housing some people slip through the cracks in fragmented service systems and they have repeated health crises that result in more trips to the hospital.
Two foundations, The California Endowment and the California Health Care Foundation collaborated to launch the Frequent Users of Health Services Initiative (FUHSI), which provided grants for planning and implementation of pilot projects in several California counties. One of the projects that received support through FUHSI was New Directions in Santa Clara County. Key partners in the project included the Hospital Council of Northern and Central California, Santa Clara Valley Medical Center, and several other local hospitals and providers of health care and services to people experiencing homelessness.
New Directions case managers are professionally trained and they receive strong clinical supervision. The team also includes access to a psychiatrist, psychological testing and services, and a medical director. Hospital emergency department staff created a system to identify frequent user patients when they arrive at the emergency department so the New Directions team can be called to the hospital to meet with clients while they are still at the hospital. Case managers facilitate linkages to primary care providers, mental health and substance abuse treatment services, medical respite services, and permanent housing. Case managers coordinate care by advocating on behalf of clients with healthcare professionals, regular case conferencing with health care clinicians, providing transportation to help clients get to appointments, offering help managing medications, and educating clients about health care and self-management of chronic illness. Case managers also offer assistance to help clients access benefits to which they are entitled, including enrollment in Medicaid or other forms of health coverage that will provide better access to ongoing health care in more appropriate settings.
While the program was launched with a focus on addressing the need for health care and treatment services, over time there was a growing recognition of the need to address housing for frequent emergency room patients who are experiencing homelessness. New Directions participated in planning and implementation of the County’s Blue Ribbon Commission to End Homelessness and collaborated with housing and homeless service providers to obtain additional resources to link the program’s services to housing assistance through Shelter Plus Care vouchers and Housing Choice Vouchers, which have been made available through a partnership with the local public housing authority.
The program receives financial support from four local hospitals that refer frequent user patients to New Directions and also from several local foundations that provide support for the medical respite program. Recently the U.S. Department of Veterans Affairs agreed to fund some respite care beds and case management services for Veterans who are experiencing homelessness.
Build and sustain strong partnerships with hospitals and community partners. New Directions began with a team based on the grounds of the Santa Clara Valley Hospital, and worked with the hospital to develop an electronic system to flag frequent user patients when they arrived in the emergency department to facilitate connections to the project while patients were still in the waiting room. New Directions staff met frequently with hospital administrators and emergency department staff to develop and refine referral linkages, and the program used support from the Hospital Council to facilitate buy-in from other hospitals in the region. The program shared data with hospitals to demonstrate its value and impact in reducing emergency room visits and hospital stays, and in response the hospitals have committed funding to sustain the program. New Directions established the Silicon Valley Health Coalition, bringing together county and private organizations to facilitate shared solutions including connections and priority access to local primary care providers, housing and homeless assistance programs, mental health and substance use programs, and benefits advocacy services to help frequent users of crisis care get the services they need.
Offer intensive case management with low staff-to-client ratios and frequent face-to-face contact. Like other successful programs that serve frequent users of emergency health care and other public services, New Directions case managers have small caseloads that average 1:20. Particularly when engaging new clients or working with clients experiencing homelessness who have very serious health problems, case managers make frequent, face-to-face visits and do whatever it takes to establish trusting relationships, educate clients about how to manage chronic illnesses, advocate on clients’ behalf to access housing and benefits, and use motivational interviewing strategies to increase clients’ motivation to engage in appropriate care and change risky behaviors. Case managers also communicate regularly with health care providers, with client consent, to coordinate care and help clients with managing medications and appointments. The New Directions team uses weekly case conferences to discuss client needs. These meetings include members of the interdisciplinary team and partners who bring clinical expertise and can help with problem solving and prioritizing access to care for shared clients.
Engage clients by offering incentives and flexible services that respond to individual needs and priorities. Small incentives such as phone cards or gift certificates for groceries or household goods can be used to provide practical support and as incentives for clients to engage in services or achieve personal goals related to stability and recovery.
Provide transportation assistance and accompany clients to appointments. Often clients experiencing homelessness are given referrals to health care providers or treatment programs that can be difficult to access without a car. Case managers provide access to public transportation options as a way to ensure that clients keep appointments for care that can help to manage chronic conditions and avoid an emergency room visit. Staff will usually meet the client at their medical appointments. By accompanying clients to appointments, case managers can help clients understand the information clinicians are providing. Case managers can then provide coaching to help clients follow through on medications or other advice and coordinate with other providers of health care and supportive services.
Transition clients over time to less intensive levels of service through tiered levels of case management to balance caseloads and maximize impact. While it is important for clients to be able to maintain relationships with team members who are familiar with their needs, over time clients need less frequent or intensive support. New Directions uses a four-tiered approach that allows clients to move to less intensive support as they become more stable and provides a caseload mix that balances workload and responsibilities for team members, allowing the program to continue to accept new clients without terminating assistance to those who need less intensive levels of ongoing support.
All clients enrolled in New Directions are connected to a primary care physician and more than half are also connected to specialty medical care. The program reported the following outcomes for clients after one year of program services:
22 percent decrease in emergency room visits
14 percent decrease in inpatient admissions
25 percent decrease in the number of days in the hospital
47 percent of homeless clients connected to permanent housing and an additional 25 percent connected to other types of housing assistance
40 percent of clients with substance use problems connected to substance use treatment
Contact Info for Follow-up:
Sherry Holm, Program Director, New Directions
(408) 272-6063 office
(408) 272-6509 New Directions Main Line
CSH's Frequent Users of Health Systems Initiative information on their website.
Evidence Based Practice: Permanent Supportive Housing
Evidence Based Practice: Housing First
Evidence-Based Practice: Motivational Interviewing
Evidence-Based Practice: Medical Respite
Promising Practice: Frequent Users of Health Services
Model Program: Chicago Housing for Health Partnership (Chicago, IL)
Model Program: Homeless Outreach and Stabilization Team
Model Program: Community Support Program to End Chronic Homelessness