In 2022, Connie Amos, M.S., Sr. Director of Post Acute Care at OHSU asked a capstone team how OHSU could better support houseless patients. Specifically, the organization noticed that discharges for houseless patients were being delayed and that they were being seen in the emergency department post-discharge because of a lack of safe housing and services. Based on their analysis, the capstone team crafted the following five recommendations:  

• Create a centralized, collaborative medical respite care program 

• Use predefined criteria to identify appropriate patients 

• Locate housing and supportive services 

• Increase the number of housing options  

• Provide onsite medical caregiver support and social services resources

The team estimated that, by serving 24 houseless patients, OHSU would increase hospital capacity by 55 in-patient beds and save 336 patient days. Not only would this allow more patients to be helped, but it would contribute positively to the financial margin.  

Since the team made their recommendations, OHSU has accomplished the following through the Safe Haven program:  

• Five reserved private apartments in an independent living facility for vulnerable, houseless patients, with provided meals and transitional care support through social work services

• OHSU staff created a risk assessment and criteria to identify patients for the program 

• Expanded the number of partner hotels for additional patients 

• Added a nurse practitioner to the care transitions team  

In under nine months, 90 patients enrolled. Of these, 72% established or re-established care with an outpatient primary care provider, 66 (73%) have an improved housing status, with 10 having moved into permanent supportive housing. Those participating also saw improved health outcomes; all patients showed a decrease in hospital readmissions and 72% of patients showed a decrease in emergency utilization. Together, that resulted in an estimated 340 saved hospital days. In addressing housing, this project helped to improve the health of participating patients through wrap-around services and the larger community through increased access to hospital beds.  

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