With community partners, Christiana Care provides homeless Delawareans with needed medical care

It’s difficult for people to make and keep medical appointments when they don’t have homes. A creative collaboration between Christiana Care’s Department of Social Work and the Sunday Breakfast Mission in Wilmington has built a bridge between medical services and homeless people, getting them the care they need so they can improve their health and become less dependent on the Emergency Department at Wilmington Hospital for treatment.

“Compliance with health care goes out the window when you’re homeless,” says Linda Brittingham, corporate director, Social Work. “There are more immediate needs, such as what you are going to eat or where you are going to sleep.”

In 2010, after Emergency Department staff noted an increase in the flow of patients from the mission, a test program was launched that focused on the city’s only walk-in shelter for the homeless. It expanded when Sunday Breakfast Mission opened a shelter for women and children.

“Christiana Care and the Sunday Breakfast Mission were both working with the same population,” Brittingham said. “We wondered what we could do better if we worked together.”

In all, 66 homeless people—48 adults and 18 children—were enrolled in the program, with diverse needs that included dialysis, vaccinations and obstetrical care. Of the group, 40 percent of the adults and 72 percent of the children remain active in the program. Of the people with a high use of hospital services, half showed a decrease in the number of visits to the Emergency Department and the number of days spent in the hospital.

Linda Brennan-Jones, a social worker at Wilmington Hospital Health Center, and Pastor Dave Jones, who directs the men’s program at Sunday Breakfast Mission, worked together to create a plan for an undocumented patient with kidney failure and severe peripheral artery disease. That included linking him to a primary care provider, obtaining medication and providing transportation to outpatient dialysis services. They also helped him to obtain identification papers so he could travel out of state to be with relatives who could offer support.

Since April, 33 additional adults have found primary care providers or medical homes through the Adult Medicine Office. To keep them on track, there is frequent communication between social workers and the shelter nurse regarding appointment reminders, transportation to the doctor, administering medications and help in navigating the health care system. Those successes have inspired other outreach initiatives.

Helping an elderly recluse whose home had been condemned required help from Christiana Care and multiple community resources. After arranging for medical care, detangling his finances and obtaining temporary housing, he now lives at an affordable community for seniors in Cool Spring, where he has access to a physician through Christiana Care’s Home Visit Program.

“The process took months,” Brennan- Jones says. “But by working cooperatively, we were able to get the job done.”

Christiana Care also has partnered with Connections, a social service agency in Wilmington that serves the homeless and people who suffer from substance abuse and mental illness. An October health fair at Connections’ Homeless Café included flu shots and a nutritious meal.

“There are so many people in need, including families that have never had financial issues before,” Brittingham says. “We are always looking for new ways to help.”