THE BRIDGE CARE MODEL: TRANSITIONAL CARE FOR PERSONS EXPERIENCING HOUSELESSNESS

Abstract Introduction Persons experiencing houselessness (PEH) are well-understood to prematurely age, experiencing higher rates of geriatric conditions at a younger age, considered “older” by age 50. Based on the rigorously-tested Transitional Care Model for older adults, UCSF Street Nursing provides low barrier care to PEH during transitions from emergency departments (ED) and in-patient admissions. Our practice focuses on: nurse-led early assessment and engagement; continuity and coordination of care; the patient-clinician relationship; holistic focus on individual patient’s needs; education and promotion of self-management; active engagement of patients and their support network; and patient-driven evidence-based care planning to address health problems and risk factors that contribute to frequent ED visits and hospital readmissions among PEH. Methods UCSF Street Nursing meets patients in the ED or in-patient prior to discharge and follows them for 6-12 months, supporting integration into community outpatient care. Clinical activities include: medication administration, wound care, street-based syphilis and STI treatment, complex care coordination, complex medication management, health education focused on self-management, and co-attending primary and specialty care visits both virtually and in-person. Outcomes: The average age of the 58 patients referred to our practice was 52 (sd=12.5). Given the premature mortality and accelerated aging of PEH, our sample represents an older adult population. Our practice produced a greater than 50% reduction in ED visits in the first 6 months following discharge. Conclusion UCSF Street Nursing is a promising nurse-led novel approach to care for unhoused older adults with potential to reduce hospitalization and improve health for an overlooked population.