Omaha's first medical respite program aims to help people facing homelessness

When Cotonna Nauden arrived at an Omaha hospital, she was suffering from sepsis, a life-threatening complication of an infection.

She awoke to find that part of one leg and some toes on the other foot had been amputated. She was in heart failure. She was in no condition to return to life on the streets where she’d been living for the previous year and a half.

So after Nauden was discharged from the hospital, she settled in a private room at the Siena Francis House, an Omaha shelter for people experiencing homelessness, where she could continue to get follow-up care as well as meals and clothing.

“That room saved my life,” said Nauden, who has been a guest at the shelter for about five months. “They truly blessed me by giving me a room and a home.”

The single- and double-occupancy rooms set aside at the shelter, as well as case management and other services that go with them, are part of Nebraska’s first formal medical respite program for people experiencing homelessness.

Siena Francis and other community partners launched the 24-month pilot project last August. The Charles Drew Health Center provides medical care in a mobile unit parked outside the shelter four days a week, a service that also is available to unhoused people who are not occupying respite rooms.

One aim of the evidence-based program is to head off cycles in which people experiencing homelessness are hospitalized for treatment, recover enough to leave the hospital but aren’t quite well enough to function on their own or in a traditional congregate shelter, which frequently results in them being readmitted to the hospital. CHI Health, through its national foundation, awarded $500,000 to cover project expenses.

E.J. Kuiper, CHI Health’s CEO, said the program has the potential to save lives, improve health outcomes and reduce health care costs by decreasing readmissions to hospitals.

“By connecting people to essential services after they leave our hospitals, we can create a pathway to stability and improved quality of life for some of the most at-risk members of our community,” he said in a statement. “We’re hopeful that with the success of this pilot program, more permanent solutions will be made available.”

The local pilot program grew out of a 2020 planning grant that provided funds to convene the Health + Housing Coalition. Facilitated by Omaha nonprofit The Wellbeing Partners, organizations from across the Omaha metro area met to identify the needs of chronically homeless and medically complex residents in the community.

CyncHealth, the health information exchange for Nebraska and western Iowa, examined the records of 450 people experiencing homelessness. The organization found that the group of patients averaged 246 emergency department visits a month in 2020, an average of nearly two per person. The same patients also accounted for 531 initial admissions to hospitals, followed by 2,062 readmissions within 30 days of being released.

“It’s something, unfortunately, that is really common in a lot of communities, and Omaha isn’t any different,” said Rachel Heinz, program manager with CyncHealth’s social care and public health teams.

Medical respite programs, which have been increasing nationally, offer an alternative. The National Institute for Medical Respite Care lists 133 medical respite programs across 38 states and territories, although the Omaha program isn’t yet included in that count.

“They can stay in this medical respite as an in-between place to continue their recovery before they’re discharged back to the shelter,” Heinz said.

Hospitals can refer patients experiencing homelessness to the program through the online Unite Nebraska platform, which was launched in 2020. The platform allows health care providers and social workers to refer patients for a variety of services available in the community. CyncHealth, which sponsors the platform, is formerly known as the Nebraska Health Information Initiative, or NEHII, and has been working to link patient records collected by physicians, hospitals, pharmacists and other health care providers in Nebraska and western Iowa for more than a decade.

Jamise Wagner, shelter director at Siena Francis House, said staff at the shelter and with Charles Drew review the referrals to make sure patients fall within each organization’s scope of care.

Respite guests must be medically stable, willing to meet with medical and program staff and able to manage daily living activities and medications on their own.

The shelter has received 49 referrals since the program launched and accepted 17 of them, she said. Some have required a higher level of care than the shelter can provide. A handful were resolved before potential guests reached the shelter, with most reuniting with family members. The shelter, which has five beds for the program, has served 11 respite guests.

Once checked in, guests in the program meet with a shelter case manager and a representative from Charles Drew within 72 hours.

Sharon Cullum-Anderson, a case manager and respite coordinator for Siena Francis, said some won’t stay in respite. A guest with a wound, for instance, may stay only long enough to complete doctor’s visits and finish healing.

But the end goal is to find permanent housing.

“Our goal at the medical respite program at Siena Francis and Charles Drew is to have them not re-enter into homelessness,” Wagner said.

Case management, she said, is a critical part of that. Case managers also connect patients with other services in the community.

Cullum-Anderson has been working with Nauden to find affordable, accessible housing that she can navigate in a wheelchair.

“This is not a job to me,” Cullum-Anderson said. “... I enjoy seeing their faces when you hand them their keys.”

But that’s a challenging task. Affordable, handicapped-accessible housing, Wagner said, is a huge need in the community, particularly with the homeless population aging and experiencing more chronic health conditions.

Having the mobile unit on-site to provide care for people with those conditions, she said, also is important.

The mobile unit is outfitted with two exam rooms. In addition to respite patients, the clinic also serves the population of Siena Francis and other people experiencing homelessness in the area, said Theresa Evans, a nurse practitioner with Charles Drew who has worked on the unit since it opened in August. The mobile unit, on site Tuesday through Friday from 9 a.m. to 3 p.m., typically sees between six and 10 patients a day.

The mobile clinic staff provide care for a variety of ailments, from wounds to sinus infections, as well as for chronic illnesses such as high blood pressure and diabetes, she said. They can administer vaccines and test for conditions such as hepatitis C and HIV.

While the mobile clinic staff schedules appointments for people with chronic conditions, they also see a large number of walk-in patients, Evans said.

Charles Drew also provides transportation to its regular clinics for patients who have mobility issues and for those who need care they can’t get at the mobile unit, including dental work and behavioral health care. The mobile staff also can initiate telehealth appointments for behavioral health care if there’s an immediate need, and make referrals for screenings such as mammograms and colonoscopies.

“I believe that medical respite can do a lot,” Wagner said. “Chronic health conditions, behavioral health conditions, cognitive and functional limitations are really common with people who are experiencing homelessness, and sometimes there just aren’t enough services within the shelter to help them meet those needs.”