For 16 years, Sarah Stella, MD, has been caring for patients as an internal medicine hospitalist at Denver Health, Denver’s primary safety-net institution.
“I have always loved caring for all my patients, but especially those experiencing homelessness. I wanted to understand what was happening to them after they left my care in the hospital and how I could better help” said Stella, who is also an associate professor of medicine at the University of Colorado School of Medicine.
So, she connected with Colorado Coalition for the Homeless Chief Program Officer Lisa Thompson, DNP, and together they applied for a CCTSI Community Engagement partnership development grant.
Stella and Thompson convened a community advisory panel, which included individuals with lived experience of homelessness, case managers, nurses and street outreach workers. Stella said Thompson and her team were critical in identifying the right people to be on that panel to shed light on what they were trying to understand.
“This partnership helped strengthen our relationship with Denver Health and allowed us to blossom,” Thompson said.
Partnership Development Project & Joint Pilot Award
Once they received initial funding, the Partnership Development Project had multiple planning meetings and they attended a CCTSI training to get to know their community partners, which helped structure the work. They met about eight times over the course of the year and learned a lot about experiences people had during and after hospitalization, especially the trauma people experience through homelessness and with healthcare.
During this time, Stella said she recognized her multiple blind spots. “We needed this perspective of people who are living this experience [of homelessness], and of people who are caring for patients,” Stella said.
Through the Partnership Development Project, they found that hospitalized patients who were experiencing homelessness often felt isolated and scared. They were having a hard time navigating in the hospital and afterwards. The group took all they had learned together and then applied for the CCTSI joint pilot award to refine and pilot a peer-led intervention to support hospitalized patients experiencing homelessness.
Outcomes of the Work
Though they were initially unable to pilot their intervention due to COVID-19 restrictions, Stella has since received additional grant funding to support implementation and evaluation of a peer-led team who will support patients experiencing homelessness and correction-system involvement.
Stella said the initial work that was funded by the CCTSI has had profound ripple effects on Denver Health, and led to impactful systems improvement work.
Before, if someone who was experiencing homelessness was hospitalized, they would likely be released back to the streets or to a shelter. Today, they can go to a 75-bed Recuperative Care Center, a first-of-its-kind facility in Colorado that is run by the Colorado Coalition for the Homeless. The organization has solidified partnerships with all major hospital systems in metro Denver. In its first year of service, the 75-bed facility served 530 individuals. More than 1,500 referrals were made this year, demonstrating an even greater need for this program.
Stella said the funding from the CCTSI, combined with mentorship and Community Engagement training and coaching, changed the focus of her career. “It was a catalyst for a lot of things: joint research, systems improvement within our learning health system. It was a catalyst for me. It changed me as a physician. It really was the impetus for creating this amazing, trusting partnership.”
Lisa Thompson, DNP, Zeina Toure, LCSW, from the Community Advisory Panel, and Sarah Stella, MD |
