Pilot Year Overview

empty-bed-in-nursing-homeThe Front Steps’ Recuperative Care Project opened April 10, 2008, with a commitment to helping homeless people who are not ill enough to occupy a hospital bed but too ill to return to the streets, shelter, or a tent. Following is a summary of the project’s pilot year, April 2008-March 2009.

REFERRALS AND ADMISSIONS

• 182 patients were referred over the course of the pilot project year.
• There were 70 referrals who met the basic eligibility criteria but for whom no recuperative bed was available.  With the timing of each referral taken into consideration, the data showed an average of 1.5 unduplicated eligible referrals on the waiting list each week.
• 30 unduplicated patients were admitted to the program during the pilot year.

MEDICAL INSURANCE

• 60% of those admitted had no medical insurance upon referral.  15 were eligible for but not receiving Medical Assistance Program (MAP) coverage; 3 were eligible for but not receiving services from the VA healthcare clinic in Austin.  All 18 of these obtained coverage.
• Applications for disability benefits, either SSI or SSDI, were filed for 18 clients during their stay in the recuperative care program; 15 of these (83%) were successful applications and these clients now have disability income and Medicaid and/or Medicare.  Decisions are being awaited on the remaining 3 applications.

SOCIAL SERVICES

• 22 clients received mental health and/or substance abuse counseling services, including referrals for psychiatric evaluations or cognitive assessments, connection or reconnection with MHMR, individual counseling sessions, referrals to chemical dependency treatment and outpatient services.
• Financial benefits (food stamps, transportation assistance, VA benefits, SSI/SSDI) were reinstated or applied for all 30 admitted clients.
• 28 clients applied for permanent subsidized housing.
• 7 clients were assisted to resolve legal issues (outstanding warrants for Class C misdemeanors for instance, or establishing payment plans for back child support).
• A long term case manager was identified for 28 clients.

EXITS

• 17 clients were exited to transitional or other stable housing.
• One patient left the program prior to finishing his treatment.
• Three patients were asked to leave the nursing home setting after several breaches of the Client Contract. This did not preclude them from accessing the social services component of the program, and 2 of these clients continued to work with the RCP case manager.
• 2 patients died while in the Recuperative Care Program; 1 patient died while living in Front Steps’ transitional housing.