It Takes a Village: A Multidisciplinary Model for the Acute Illness Aftercare of Individuals Experiencing Homelessness

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Abstract
Homeless individuals are often uninsured and are more likely than the housed to utilize acute health care services and experience longer hospitalizations. Currently in the United States, there are fragmented services available for the aftercare of these patients to ensure continuum of care, promote healing, and avoid re-entry into the acute care system. The Fourth Street Clinic Respite Program was created to address these issues. Patients are referred to the program from local hospitals and other service providers. Based on the acuity of illness and need for nursing care, patients are admitted to one of four programs: (1) Shelter-based Day Bed Program, (2) Temporary Emergency Housing (Motel) Program, (3) Tuberculosis Housing Program, or (4) Nursing Home Program. Aftercare patients receive medical, social, and behavioral health services and are discharged to local shelters when stable. The aftercare program provides a safe refuge for recovery from acute illnesses for those experiencing homelessness.