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Nursing supports development of medical respite unit for people experiencing homelessness released from hospitals

Clinical Scholars teammates and collaborative stakeholders in front of the Buffalo City Mission.

Team members pose in front of the Buffalo City Mission, where a new medical respite care unit shelters men experiencing homelessness after they've been released from the hospital. Photo: Pat Cray


Published September 25, 2023

Amanda Joy Anderson.
“What is less well known is that there is a growing population of people experiencing homelessness without a single place to go after devastating hospitalizations. ”
Amanda Joy Anderson, PhD candidate, research assistant and Robert Wood Johnson Foundation Clinical Scholar

Researchers from the School of Nursing have used a nationally prestigious Robert Wood Johnson Foundation grant to foster synergy among a myriad of service agencies and build a “safe, efficacious and efficient” medical respite unit in the men’s shelter of the Buffalo City Mission to help men experiencing homelessness after they are discharged from hospitals.

The 13-bed facility in the mission’s Alfiero Family Center provides intensive case management, coordination of medical and social needs, and shelter for homeless men released from hospitals.

“In the last year, Buffalo experienced a dramatic rise in the number of people experiencing homelessness in the region,” says Amanda Joy Anderson, PhD candidate, research assistant and Robert Wood Johnson Foundation Clinical Scholar, who first learned of the possibility for collaboration between the nursing school and the mission during a research practicum in her first semester as a doctoral student.  

“This is a well-known fact. What is less well known is that there is a growing population of people experiencing homelessness without a single place to go after devastating hospitalizations,” Anderson explains. “As such, they remain hospitalized for extensive periods of time, which places them at risk and harm, but also impacts our region’s already scarce acute care supply.

“In short, these patients — patients who might benefit from medical respite care — are too sick for a street-side discharge, but too well to remain in the hospital.”

Prior to the project, when the patients the center now serves did leave the hospital — whether they entered another facility or tried to live on their own — they were met with “an incredible burden to successfully transition to the community,” she says.

“On top of their preexisting social need, many suffer from extensive health needs and, unfortunately, return quickly to the hospitals for further care.”

The dilemma for providers in both sectors — health and social services — is complex and compound, according to researchers.

“Our clinical scholars team had to bring cross-sector providers together to figure out how to collaborate in a new way, both in providing services to the patient and also in managing relationships between the organizations,” says Sharon Hewner, associate professor of nursing “Unfortunately, the community has limited resources to care for these patients and prior to our program, none existed in a 250-mile radius.”

The UB project fills that need.

“We learned early on how complicated it was to maneuver the health and social services systems,” says Hewner. “It is such a patchwork of organizations with different missions and agendas.”

Nevertheless, their efforts resulted in an advisory board to deal with system issues and build more reliable ways to ensure safety and quality during care transitions.

A shelter case manager in the medical respite unit inside the Buffalo City Mission.

Tameka Ealey, supervisor of the Buffalo City Mission's recuperative care unit at the Alfiero Family Center of Hope and Promise. Photo: Pat Cray

The work officially started in fall 2020, when Anderson was completing a research practicum at the City Mission.

“I was trying to understand the ‘wicked problem’ (of people experiencing homelessness released from hospitals) that might be solved with a medical respite program,” says Anderson.

She approached Hewner about writing a grant to support further work together at the City Mission, which was building a new facility adjacent to its existing structure. The grant — the Clinical Scholars Fellowship, a three-year national leadership program supported by the Robert Wood Johnson Foundation — allowed the School of Nursing and other agencies “to pool our expertise in care transitions as an administrative support to the mission as they launched a new kind of program, in a new sector of care for them,” says Anderson.

Over the past three years, the funding allowed the clinical scholars team to work closely with the team at the mission to set in place key program elements, such as eligibility criteria, and broker key connections with area hospitals so that they could make contracts for accepting patient referrals. 

Anderson and Hewner say the medical respite center also represents an outstanding example of a collaborative “network” among medical and social organizations designed from inpatient hospitals, social sector organizations and community-based care organizations, which is further outlined in a paper recently published in the journal Frontiers in Health Services.

“The result was two teams of health and social service workers, working across organizational and professional boundaries,” says Hewner.

Anderson called the progress and process — from the initial idea to the prestigious national fellowship, to deliverables that the community can now use to help sustain this program and work — something from which others can learn.

“It was a cathartic experience to be funded as a doctoral student, invested in through the Clinical Scholars Fellowship alongside nationally acclaimed leaders, and learn how to engage in community-based research while assisting the community,” she says.

Anderson also authored and presented a TED-style talk, the Clinical Scholars “Big Idea Talk,” on the evolution and implementation of the project.

“The Big Idea Talk shows the relationality that this type of work requires — people coming together despite organizational and sector boundaries — for patients that are in need,” Anderson says. “And the toolkit that our clinical scholars team authored puts us within a historical collection of other RWJF Clinical Scholars.

“We are the final cohort of this legacy program, and that feels fantastic that we added the UB name into such a world-changing group of people.”