Pathway to Health and Home
Pathway to Health and Home evolved from longstanding efforts to address critical service gaps for patients discharged from the hospital but still require care and a place to stay and recover.
UniHealth Foundation has partnered with Cedars-Sinai and Providence Southern California to commit $15 million in grantmaking and program-related investments over two years to improve the healthcare of those experiencing homelessness in Los Angeles County. The funding initiative, called Pathway to Health and Home, identifies collaborations and partnerships between healthcare and housing providers to better integrate clinical services into interim and supportive housing units. The collaborative philanthropic effort aims to improve health outcomes and reduce the influx of people experiencing homelessness into hospitals and emergency rooms.
Pathway to Health and Home evolved from longstanding efforts to address critical service gaps for patients discharged from the hospital but still require care and a place to stay and recover. For more than a decade, UniHealth Foundation has invested in programs that support people experiencing homelessness as they progress from hospital discharge to permanent housing. A wide variety of services and supports are required along the way, and UniHealth has identified many interventions that help make patients’ journey healthy and successful.
Downtown Women's Center
Downtown Women’s Center (DWC) was awarded $500,000 over three years to expand its model to support aging in place for older adult women residing in Permanent Supportive Housing (PSH). DWC’s work is influenced by the CAPABLE (Community Aging in Place, Advancing Better Living for Elders) model, a program developed at the Johns Hopkins School of Nursing for low-income seniors to safely age in place. The model integrates the support of Registered Nurses and Occupational Therapists, which ensures that its older adult residents and residents with geriatric health conditions are able to safely age in place by addressing the chronic health and mental health challenges that pose threats to their housing stability. The grant will allow DWC to extend services to 245 additional units of PSH over three years and add RN and OT staff to serve aging women in these units. The grant also funds a Director of Programs to implement the model and coordinate staff training at new and existing sites. UniHealth funded an earlier phase of this program that provided RN and OT support to residents in DWC’s 119 units of on-site PSH. RNs provide post-hospitalization follow-up to ensure that residents are discharged with an appropriate level of home health care support, which is critical for reducing re-hospitalizations and for ensuring long-term housing stability. The first phase of demonstrated the tremendous value in having OT capacity onsite to support its residents’ housing stability; 98% of the women who interacted with OTs have retained their housing after one year. A Pathway to Health and Home funding expands this successful model to more PSH units and allow more aging patients to remain in housing.
HOPE empowers people with intellectual/developmental disabilities (I/DD) to become valuable, contributing members of their communities. HOPE was awarded $150,000 over 12 months to expand the capacity of its Housing Services Program, which assists people with I/DD in identifying appropriate housing with affordable rents, completing the application process, coordinating their move-ins, coaching on good housemate and landlord relations, and evaluating for accessibility-specific renovation needs. At the beginning of the grant period, 73 tenants with I/DD living in HOPE’s Independent Living properties were not yet receiving housing services and 138 people were on its waitlist. The support services provided by its small staff improves client mental and physical health, but HOPE could not meet demand. To continue to grow these housing services and their impact in the community, A Pathway to Health and Home funding supports program improvements including: A) developing new tactics to reserve housing units, B) enhancing staff capacity to increase caseloads, C) integrating a new client relationship management (CRM) database system. Adding staff resources to communicate with clients, assist them in accessing housing, and secure more units to place clients in suitable housing, will allow HOPE to better serve its I/DD clients. The housing supports funded by this grant have proven to keep people in stable housing and improve mental and physical health.
In 2018, UniHealth Foundation committed to be a philanthropic leader and supporter of recuperative care work. The UniHealth Board of Directors designated $1 million over two years towards recuperative care projects.
Consultation with our hospital and service provider partners led to increased investment in promising strategies that facilitate transitions from hospital to home. These include support for recuperative care, a transitional alternative to a hospital bed where a person experiencing homelessness can heal after a hospitalization or medical emergency. Increased focus on mental health needs, navigation into social services, case management, and street medicine have improved access and delivery of effective care for people experiencing homelessness.
Pathway to Health and Home builds on the previous work UniHealth has accomplished with, and learned from, its grantmaking over the past several years. In 2018, UniHealth Foundation committed to be a philanthropic leader and supporter of recuperative care work. The UniHealth Board of Directors designated $1 million over two years towards recuperative care projects. Cedars-Sinai Community Benefit decided to support this work by granting UniHealth $250,000. In 2020, this collaboration expanded again – Cedars-Sinai invested another $5 million and Providence Southern California has invested $1.2 million.
Pathway to Health and Home emphasizes three focus areas: (1) communication and collaboration, among housing and healthcare providers, payors, funders, and public agencies; (2) embedding clinical services in housing, including recuperative care housing; and (3) improving care transitions via linkage, navigation, and training with a focus on seniors/elderly. In its first year, Pathway to Health and Home targeted the health issues of older adults falling into homelessness. Older adults are falling into homelessness at higher rates than ever before and housing facilities and staff find themselves ill-equipped to address the needs of this population. Addressing long-term, chronic care issues is a priority for the initiative. Pathway to Health and Home funding has supported programs to improve the health of patients experiencing homelessness and help the transition to permanent housing.