January 10, 2025
We’re excited to present a first look at our NEW AHCH-led Medical Respite Collaborative at the Gateway Center
–A transformative collaboration led by Albuquerque Health Care for the Homeless (AHCH). Launching in early 2025, this innovative initiative will expand access to integrated health care for individuals experiencing homelessness, offering a safe, supportive environment to recover from illness or injury.
Dignity, Safety, and Hope “This center will provide more than just medical support; it will offer dignity, safety, and hope, connecting individuals to resources for long-term stability and housing,” shared Daniel Rowan, Sr. Program Manager at Project ECHO and AHCH Board Member. “It reflects our belief that everyone deserves the chance to recover and rebuild.”
Medical Respite: Explained When an unsheltered individual is discharged from the hospital following surgery or another major injury or illness, they frequently find themselves without a safe space to recover. This often forces our unsheltered neighbors to recover on the streets, where they face challenges that lead to worsening conditions and rehospitalization. Medical respite initiatives have grown in popularity nationwide as a solution to meet this gap in care. Medical respite provides a place for people without homes who are not ill enough to remain in a hospital but are too ill to recover on the streets. They provide short-term residential care that allows people who are homeless to heal, bridging a critical gap in the continuum of care for vulnerable populations. It also will ensure that people have a safe space to engage with services, outside of just their health care. Clients will have the opportunity to get connected into AHCH’s integrated health care networks and receive not just follow-up medical care, but preventative primary care as well as dental, or behavioral health care.
The program, launching in early 2025, is an extension of AHCH’s integrated care model, addressing physical health, mental well-being, and social determinants of health to foster recovery and stability. Medical respite bridges the gap for those who are too ill to recover on the streets but do not require hospitalization. Building on the existing current social respite model in Albuquerque, which only provides shelter for rest and recovery, this program offers comprehensive medical care, reducing hospital readmissions and improving health outcomes, while also supporting individuals in exiting homelessness into housing.
A Long Time Coming: This exciting project has been a long time coming. Following an eight-year planning process lead by Albuquerque Health Care for the Homeless (AHCH), which included a robust needs assessment, a national technical assistance convening, and an independent evaluation workgroup, the Albuquerque Medical Respite Collaborative is well positioned to launch comprehensive services. The Medical Respite Work Group was initially formed in 2017 by AHCH and included the City of Albuquerque, UNMH, Heading Home, and Barrett Foundation. The Medical Respite Work Group conducted a needs assessment of the current model and found that the current medical respite infrastructure was not meeting the needs of the community. It still had a high exit back into shelters and high readmissions to expensive hospital care.
In a 2021 report following the Needs Assessment, AHCH recommended a sustainable Medical Respite model to reduce homeless mortality and increase access to care and services. The report cites data from the National Health Care for the Homeless Council that states readmission to the hospital is two times higher for individuals who are homeless. It also reveals that patients experiencing homelessness stay about four days longer per admission than other low-income patients. Recent homeless mortality data underscores this urgent need for medical respite care – people who are unhoused die 20 years earlier than housed people and have 60% greater mortality risk than other poor, but housed, people.
With these findings, AHCH lead the charge in designing a robust medical respite program in collaboration with CABQ, First Nations Community Health Choice, University of New Mexico Hospital, and Heading Home. In 2020, CABQ purchased the old Lovelace Hospital and began renovating it into the Gateway Center, a hub of services supporting the community and the new home of the Medical Respite Center. The site broke ground on December of 2023, and now sets its sights on opening its doors for operation in early 2025.
Designing Trauma-Informed Healing Spaces: Spanning 22,500 square feet, the Medical Respite Center offers 50 beds in individual and shared rooms, daily onsite medical, behavioral health, and dental care, along with wraparound services like housing navigation and case management. Each room is ADA accessible and has easy access to restrooms and showers with ample natural light, privacy, and lockable drawers to protect belongings and medications. The facility also includes offices for case management, communal dining areas, a large space for physical therapy and exercise, as well as laundry services on site.
Creating a Scalable Model for Transformative Impact: This initiative will serve as a national model, showcasing how medical respite can improve transitions from hospital to home, reduce homelessness, and build healthier communities. This medical respite model prioritizes healing, so individuals can stay as long as they need to heal. However, that doesn’t mean that once individuals have recovered they will be discharged back to the streets that made them sick in the first place. AHCH also advocated for the City of Albuquerque to provide dedicated housing vouchers for medical respite clients, ensuring that clients will have the opportunity to exit into housing and be supported by AHCH’s social service staff. Additionally, AHCH leveraged a 1115 Medicaid Waiver Pilot to demonstrate a model for sustainably funding Medical Respite sites. Finally, AHCH secured an independent evaluator who will assess the Albuquerque Medical Respite model and establish standards for Medical Respite that can be scaled and implemented throughout the nation.
We invite you to join us in celebrating this milestone and supporting ongoing efforts to advance health equity and end homelessness in Albuquerque. Stay tuned for updates, client stories, and opportunities to get involved!
Frequently Asked Questions (FAQ’s):
What is Medical Respite?
Think of it like a ‘home’ environment for people as they recover from illness or injury. If you were in the hospital getting surgery, your surgeon would eventually discharge you home to finish recovering. Patients who don’t have a home to recover in, need medical respite. Medical respite will also provide pre-admission care to help an individual prepare for surgery or prevent hospitalization. Simply put, Medical respite provides a place for people without homes who are not ill enough to remain in a hospital but are too ill to recover on the streets.
Who is Medical Respite for?
Clients must be experiencing homelessness, over 18 years old, have an acute medical condition, and meet the inclusion criteria for medical respite including ability to perform all activities of daily living.
Is Medical Respite a new concept?
No. This is a care model that has been done across the country in a variety of different models, and we worked hard to bring it here to serve our community. We worked with the National Health Care for the Homeless to follow the national standards, and have visited other respite programs around the country. We’ve had medical respite services through our motel vouchers and our medical respite voucher program historically, but this is the first time we’ve had a designated space to help folks recover. While medical respites vary, all programs shares the same fundamental elements: short-term residential care that allows people experiencing homelessness the opportunity to rest, recover, and heal in a safe environment while accessing medical care and supportive services.
How is this different from other medical respite beds in Albuquerque?
The new program builds on, and is additive to, the current programs we already have in Albuquerque (including Heading Homes’ Albuquerque Opportunity Center (AOC), Barrett Foundation, the Good Shepherd, and medical respite motel vouchers), filling a crucial gap and need for medical respite care. The Albuquerque Medical Respite Collaborative is distinct and additive to the current services as it provides integrated and continuous health care on site. Additionally, AHCH will manage dedicated housing vouchers through the City of Albuquerque and provide robust housing navigation to ensure medical respite clients exit to housing.
What is AHCH’s role?
AHCH will be the primary medical service provider. An AHCH Nurse Manager will be onsite full-time Monday-Friday, to handle intakes and discharges, along with a medical assistant, patient access representative, community health worker, and social services provider. AHCH will have an integrated primary care team onsite to see patients clinically for appointments and help them with their medical goals.
What is Heading Home’s role?
Medical Respite shelter operations (food, linens, etc.) will be handled by Heading Home staff, who will be onsite 24-7.
What is UNMH’s role?
UNMH will provide hospital discharge and patient care coordination services within this collaborative relationship. UNMH staff in the hospital will assist with care coordination and referrals in partnership with the AHCH Medical Respite Nurse Manager in charge of the program.
What is First Nations Community Healthsource’s Role?
First Nations will provide primary care on site in partnership with AHCH.
What is the City of Albuquerque’s Role?
CABQ is providing the space, renovated the facility, and holds the contract with Heading Home for shelter operations.
Who’s paying for these services?
- · The City is providing the space and paying for the shelter operations.
- · When AHCH or First Nations sees patients in a provider visit they will bill for those services as they currently do as Federally Qualified Health Centers. However, AHCH and First Nations will always provide care regardless of ability to pay.
- · Medicaid is providing additional funding to help cover Medicaid-eligible patients on a daily rate through a special waiver that AHCH helped to advocate for.
How does the referral process work?
Because this is a pilot program, the Albuquerque Medical Respite Collaborative is only accepting referrals from the following places: UNM Hospital, First Nations, and AHCH providers. All referring providers must fill out a referral form and fax it over to respite. Then the AHCH Nurse Manager at Respite will review and process the referral.
How long can clients stay in medical respite?
On average, clients will stay 45 to 60 days. However, length of stay will be determined by the AHCH care team and can be extended based on medical need.
There are both individual and shared rooms, how are room assignments made?
AHCH and Heading Home have a protocol for assigning rooms based on medical needs, behavioral health considerations, accessibility needs, gender identity, etc.
What are the shared spaces in the respite facility for?
Clients will have access to shared living spaces, places to eat meals, an Occupational Therapy/Physical Therapy space for rehabilitation, and group and individual rooms for provider visits, case management meetings, and group therapy including integrated behavioral health and primary care medication assisted treatment for opioid use disorder.
What other services are provided on site?
- Onsite case management/care coordination including:
- -Coordination and/or transportation to offsite medical appointments
- -Completion of case management and supportive services onsite as applicable
- -Referral or connection to community case management services as applicable
- Connection and transition to primary care provider/health home before discharge
- Onsite clinical services including:
- -Creation of individual clinical care plan by an appropriately licensed clinical provider.
- -Daily evaluation (or as indicated by clinical care plan) by an appropriately licensed clinical provider.
- -Provision of medical clinical services within scope of licensure and as indicated by discharge instructions and clinical care plan.
- -24/7 access to a provider on call and a nurse advice line.
- -Medication management
- -Chronic condition management by appropriately licensed clinical provider.
- -Medical management and treatment by an appropriately licensed clinical provider.
- -Behavioral health by licensed clinical social worker
- -Care coordination with home health and home-based clinical care services
- -Other integrated health services as needed including dental, harm reduction, art therapy, public benefits enrollment, housing navigation, community health workers, and housing navigators to facilitate exit to housing.
- -Provision of all clinical services will be conducted by appropriately licensed, trained, credentialed, and privileged providers which may include Registered Nurses (RNs), Doctor of Medicine (MDs), Advanced Practice Providers (APPs), Dentists, Dental Hygienists, and Licensed Clinical Social Workers (LCSW), and will be based on individual patient needs as outlined in the care plan.
