Medical Home Without Walls provides care to the homeless, disenfranchised

Medical Home Without Walls provides care to the homeless, disenfranchised

medical workers and homeless man in a park
Erica Locke, M.D., and social worker Tracy Pearson meet with Anthony Iubatti in a park in downtown Wilmington. Iubatti, who is homeless, is a patient in the Medical Home Without Walls program, which aims to provide high-quality, coordinated care to people who might otherwise receive their only health care through frequent visits to the emergency department.

Christiana Care has launched a dynamic initiative called Medical Home Without Walls to reach “super users” of the acute-care system, a group that comprises fewer than 10 percent of all patients but accounts for more than 20 percent of all visits to the hospital.

By visiting patients at their home or shelter, accompanying them to medical appointments and addressing social ills such as hunger, addiction and domestic violence, the program provides coordinated care to people who might otherwise only receive care through frequent visits to the emergency department.

Medical Home Without Walls is modeled on a successful program in Camden, N.J., that reduced health care costs 56 percent by dramatically decreasing the need for emergency care. A dedicated multidisciplinary team identifies super users and then connects them with a medical home, coordinates clinical care and addresses their psychological and social needs.

“Doctors can write prescriptions all day, but they can’t buy the medicine and make patients take it,” says Erica Locke, M.D., a third-year resident in emergency and family medicine who helped to launch the program. “This program is about trust — patients working with a doctor or nurse and realizing that their health is their own, and they have a say in it.” She says this hands-on initiative has the potential to transform the lives of patients who feel disenfranchised from the mainstream health care system.

Locke and social worker Tracy Pearson shadowed a team in Camden to gain firsthand experience before launching Christiana Care’s program in Wilmington. In its initial stage, Medical Home Without Walls is focusing on patients in three ZIP codes who do not have health insurance. Many of the patients are homeless.

“We will connect them with resources in the community, such as shelters, food banks and medical insurance,” said Tracy Pearson, the team’s social worker and health coach. “We are building relationships with other organizations so we can work together to help these people.”

“These are patients with complex medical problems, as well as high risk factors such as homelessness and substance abuse,” said Diane Bohner, M.D., medical director of Patient and Family Centered Care and Resource Management at Christiana Care. “Caring for neighbors in need, regardless of their ability to pay, is consistent with The Christiana Care Way. If we can help to keep a patient healthy in the community, the health system saves the cost of hospitalization, which is about $1,300 a day. But more importantly, it greatly improves the patient’s quality of life, as defined by the patient.”

Medical Home Without Walls is part of Christiana Care’s Care Link Services. Care Link Services encompasses all Christiana Care programs related to population health — an approach that tackles the health issues of specific groups of individuals. Other Care Link Services programs and activities include the Visiting Nurse Association’s disease management program, the Independence at Home project for chronically ill seniors, two Patient Centered Medical Homes practices, the efforts of hospital-based care managers/social workers and Bridging the Divide, a program for patients with chronic heart disease.