ConnectCare

Grantee: Downtown Emergency Service Center (DESC)
Timeframe: July 2023 – June 2026 | Amount: $525,000

• Year 1: July 2023 – June 2024. Amount: $175,000
• Year 2: July 2024 – June 2025. Amount: $175,000
• Year 3: July 2025 – June 2026. Amount: $175,000

DESC serves individuals with complex behavioral and physical health conditions, many of whom are unhoused or have experienced long-term homelessness. These individuals face extreme health risks, including chronic illness, injury, trauma, and early mortality. Studies show that people experiencing homelessness often exhibit health deterioration 20 to 30 years earlier than the general population, and those with behavioral health disorders die at disproportionately high rates. Despite Medicaid access, many DESC clients avoid healthcare due to past trauma and difficulty navigating fragmented systems.

For over 40 years, DESC has focused on improving health outcomes for this population through integrated services and strong partnerships, most notably with Harborview Medical Center (HMC). Among DESC’s 4,332 clients with health data in 2022, 75 percent had mental illness, 51 percent had substance use disorders, and 31 percent had serious medical conditions. These intersecting issues, combined with poverty, aging, and systemic racism, create significant barriers to care.

ConnectCare, launched in 2020 with HealthierHere funding, was designed to bridge gaps between behavioral and physical healthcare systems. It focuses on a high-need subset of about 300 DESC clients who are also HMC patients. Of these, 45 are actively enrolled. The program prioritizes intensive, individualized coordination to reduce hospitalizations, improve treatment outcomes, and connect clients to essential care.

The model includes identifying care gaps, low-barrier outreach, strengthened communication with HMC providers, and a multidisciplinary team approach. It uses trauma-informed, harm reduction strategies and emphasizes meeting clients where they are. This is especially important for clients who avoid scheduled appointments or are not currently engaged in services.

Feedback has been positive: in a recent survey, 100 percent of ConnectCare clients strongly agreed the team helped them feel respected and supported in managing their health. The team includes five full-time staff and a part-time data analyst. As HealthierHere funding ends, DESC is using unrestricted funds to maintain one care coordinator and plans to transition ConnectCare into its medical services portfolio. The agency is also exploring becoming a Certified Community Behavioral Health Clinic, which would improve sustainability through expanded billing options.

ConnectCare is a proven, effective model for reaching the highest-acuity clients and coordinating care across systems that often fail to serve them. It ensures that individuals with the most complex health needs receive consistent, compassionate, and integrated support.

ABOUT OUR GRANTEE

Downtown Emergency Service Center (DESC)

DESC’s mission is to help people with the complex needs of homelessness, substance use disorders, and serious mental illness achieve their highest potential for health and well-being through comprehensive services, treatment, and housing.