ConnectCare

Grantee: Downtown Emergency Service Center (DESC)
Timeframe: July 2023 – June 2024 | Amount: $175,000

Homelessness is undeniably hard on human bodies. The people served by DESC have high risks for injury, illness or death on the streets, and even those who are housed experience broken bones, burns and other wounds, systemic short- and long-term infections, and worse health outcomes across a wide range of disease states than their higher-functioning peers. Studies have shown that current or formerly homeless people live in bodies that exhibit signs of deterioration 20-30 years younger than the general population at the same chronological age. Other research has shown that people living with severe behavioral illnesses also die earlier and at a higher rate. Many of DESC’s subpopulation of the homeless have experienced trauma in seeking past medical care and are often reluctant to engage with healthcare providers, even when they are very sick. Even if they have Medicaid, navigating multiple and confusing healthcare systems, especially when they are ill, is just too daunting.

For 44 years, DESC has had a laser focus on helping this population, developing and implementing innovative integrated healthcare services across the whole array of the agency’s services and programs. We have enjoyed strong partnerships with healthcare providers in the King County region, most notably with Harborview Medical Center (HMC).

Among DESC’s 4,332 clients in 2022 for whom we have health information (73% of total unduplicated clients):  75% are living with mental illnesses, 51% are living with substance use disorders, 31% are living with serious medical conditions, and 30% are living with physical or developmental disabilities. Most fall into more than one of these categories, and many are challenged with all of them. These characteristics, combined with the usual conditions related to aging (42% are over age 50, including 133 clients over age 75), experiences of violence, and systemic racism result in complicated healthcare profiles for people with little consistent access to health providers across the board.

Prior PHPDA Major Grant awards to DESC have served thousands of people and delivered care across a wide swath of health needs. ConnectCare is different in its priority to serve fewer clients whose combined behavioral and physical illnesses put them at the very highest acuity of debilitating conditions or death by providing intensive coordination and direct engagement with HMC and other providers. The program increases access to primary and specialized healthcare and improves health outcomes by offering deeply individualized whole person treatment and support. While DESC strives to meet all the healthcare needs of our clients, resources needed to manage care for clients with the highest acuity of complex critical conditions are limited. Case managers have many priorities for their clients’ well-being and are less likely to be able to also manage complicated medical case management activities.

ConnectCare began in 2020 as a pilot project funded by King County HealthierHere to bridge the gap between behavioral and physical healthcare systems, where too many DESC clients fall through the cracks. In addition to core elements of the model (intensive integrated care planning, connections between providers, and effective communication), we have added assertive outreach and engagement activities to meet clients where they are, whether they are currently participating in services or not. The ConnectCare model employs trauma-informed, destigmatizing and harm reduction approaches as well.

The target population for ConnectCare is approximately 300 DESC clients who are also served by HMC, 45 of whom are actively engaged with the project to date.

Coordinated healthcare access, treatment and follow up “for people with diabetes, cancer, or asthma, methadone treatment, mental health treatment, and issues with food security and housing stability are not in and of themselves complex challenges; the complexity arises when the tasks of making connections among multiple care providers and linking each intervention to the individual’s overall care plan fall in the lap of the individual alone without effective partnering or support. Care coordination reframes the complexity as one posed by the care systems, not by the individuals, and offers an elegant solution in the form of individualized, wrap-around planning and supports. When done effectively, care coordination holds the promise of helping individuals take on more and more of their own health-fostering activities over time, freeing the care coordinator to assist others.

DESC’s ConnectCare (also known as the case coordination project or the shared registry) has four primary components:

1. IDENTIFY gaps in healthcare for clients served by both DESC and HMC (“shared clients/patients”) who experience multi-morbidities and co-occurring disorders.
2. CREATE a low-barrier, assertive outreach and engagement plan to meet clients where they are (housed or unhoused).
3. ESTABLISH and EXPAND current relationships with HMC providers and staff to streamline communication and decrease response time for shared-client care.
4. LEVERAGE multidisciplinary team for wrap-around client support.

DESC clients can participate in a variety of feedback methods, including an overall agency Consumer Advocacy Board and periodic focus groups or surveys. Recently, a client satisfaction survey of those served by ConnectCare demonstrated positive responses – 100% of clients surveyed strongly agreed that the Care Coordination Team “helps me feel respected and supported in my health and wellness.”

ConnectCare has been comprised of five full-time staff and a part-time data analyst. Funding from HealthierHere for the two-year pilot project will end this spring. DESC feels so strongly about the efficacy and success of the work that we will cover the expenses of one Clinical Care Coordinator from unrestricted contributions until we know whether we will be awarded a Major Grant. DESC plans to move ConnectCare from its current place in SAGE (Support, Advocacy, Growth and Employment), DESC’s major outpatient behavioral treatment services, and into the medical array of services. This will better position the project for seamless coordination between DESC and external healthcare providers, and potentially improve the prospects for long-term sustainability. DESC leadership is currently exploring the possibility of a strategic shift to become a Certified Community Behavioral Health Clinic (CCBHC), which may allow us to partner directly with MCOs and afford more flexibility in billing directly for physical medical services than we are able to do now.

ConnectCare brings a structured framework for DESC and HMC to effectively serve the highest acuity clients in our shared population, and it has proven to be an effective tool for helping people too often locked out of siloed healthcare delivery systems or left behind because of the complexity of their needs.

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.