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Winter Shelter Care Coordination

Winter Shelter Care Coordination

snow over shelter

Washington County, Kaiser Permanente, and Health Share are participating in the Healthcare + Homelessness (H +H) Project as one of five communities in a national cohort convened by Community Solutions and the Institute for Healthcare Improvement. The goal of the H + H Project is for health systems to partner with the County to help achieve measurable progress toward ending chronic homelessness, with a focus on building racially equitable systems. As part of this effort, the project team identified a gap in access to health care services for individuals utilizing the County’s winter shelters, many of whom are Health Share members. 

During the 2021-2022 winter, Washington County is funding five winter shelters for youth, individuals, and families. Many individuals accessing winter shelter may be coming indoors after spending a prolonged amount of time outdoors. Some participants have complex, longstanding medical needs, and the vast majority of these individuals are either eligible for Medicaid or already enrolled with Health Share. To meet the needs of these guests, a case conferencing pilot is being implemented to support the acute health care needs of medically vulnerable participants in the winter shelter system.

In order to address the gap in access to health care resources experienced by medically fragile individuals staying at the five Washington County winter shelters, the team developed a Winter Shelter Case Conferencing Project in early 2022. The primary goal of this project is to increase collaboration between health and housing systems to meet the health care needs of medically fragile Health Share members who are accessing these shelters. The project will provide care coordination for winter shelter residents through case conferencing between shelter case managers, Health Share staff, and the CCO’s health system partners, ensuring that members with special health care needs have access to integrated and coordinated care. When medically vulnerable individuals are identified from the winter shelters, the case conferencing team will review the selected case(s), assess the medical needs and barriers to care, and then problem-solve together to address health concerns.  In addition, through this process, systemic barriers to care will be identified for people experiencing homelessness and housing instability, which will help to inform quality improvement efforts within health systems to improve the health outcomes of members.