A pilot program is underway in San Diego County to bring health care and services to unhealthy homeless people who frequently use emergency rooms. The goal of Whole Person Wellness is to provide a path for healing while saving millions in Medi-Cal costs.
“This program provides intensive care management for up to two years to help them navigate that maze of services and housing and all the things they need,” said Susan Bower, assistant director of integrated services with the county’s Health and Human Services Agency. “So that they can become stable and not hit the hospital, not hit the emergency departments, not go to jail.”
The county has contracted with two homeless service groups: Exodus Recovery and PATH — People Assisting The Homeless. Since January, their teams of outreach workers have been searching for 1,049 homeless people who had accumulated $20,000 or more in Medi-Cal costs over the past year.
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The people targeted were also identified as being chronically homeless and suffering from a severe mental illness, substance abuse disorder or physical illness.
Bower explained it takes time for outreach workers to build a relationship and trust, but once a person is enrolled in the program, they are teamed with case managers, health workers and a housing navigator who guides them through an array of services.
“They go out on the streets and work with the individual,” Bower explained. “They don’t have the person come to the office.”
“Thousands and thousands could benefit from this,” she said. “The beauty of this program is it meets all your needs. It’s not just a mental health program or just a housing program.”
Bower said the result is fewer expensive trips to emergency rooms.
“They may not need to go to an emergency department all the time but that’s the one that they know,” Bower said. “So maybe what we can do is have the clinic be the one that they know. And so they go to the clinic instead.”
Initially, outreach teams were having trouble finding people on the list, Bower said.
“Trying to find somebody with just a name and very limited information is very challenging,” she said.
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So a change was recently implemented to allow hospitals to directly contact the program when they have a patient who may benefit.
“If they see individuals who are frequently coming in over and over, they can just refer them in. They don’t have to be on a predisposed list," she said.
Bower said the partnership opens the gates for more people to be enrolled in the program. As of May, 53 people were signed up, with another 150 in the outreach phase.
The program is paid for by a $22 million federal grant, which the county is matching.
