How to best support medical patients without homes

By Kevin Manne

BUFFALO, N.Y. — After unhoused people leave the hospital, they achieve the best outcomes when leaders and frontline staff at health and social service agencies work together to provide care, according to new research led by the University at Buffalo School of Nursing, in collaboration with the UB School of Management and UB School of Public Health and Health Professions.

Available online ahead of publication in the Journal of Interprofessional Care, the study examines how medical respite programs (short-term care for people experiencing homelessness post-hospitalization) facilitate collaboration to deliver the best care for these patients.

“The inspiration for this study came from early brainstorming sessions on the ‘wicked problem’ of managing the complex care needs of persons with housing instability,” says lead author Amanda Joy Anderson, PhD. “While stable housing is a critical gap, we focused on modifiable factors relevant to our nursing expertise: refining health care delivery during care transitions, where breakdowns in important things like medication management and post-hospitalization care can occur. For individuals without stable housing, the burden of managing these transitions is exponentially greater largely due to the sheer volume of cross-sector providers needed to meet complex needs.”

A 2024 doctoral graduate of the UB School of Nursing, Anderson serves as an adjunct instructor in the school and is an advanced mental illness research and training postdoctoral fellow with the U.S. Department of Veterans Affairs supported by the National Center on Homelessness Among Veterans at the James J. Peters VAMC VISN 2 Mental Illness Education, Research and Clinical Center.

To measure how these groups work together, the researchers studied 15 organizations in a Buffalo medical respite program, collecting data from 20 administrators and more than 40 frontline care coordinators through interviews and surveys on collaboration frequency, communication, relationships, coordinating mechanisms and role attributes. They then used social network analysis to map connections and relational coordination scoring to measure teamwork quality, comparing results between administrative and frontline groups.

Their findings show that to best serve their unhoused patients, medical respite programs and other transitional care initiatives should develop consistent meeting structures, integrate frontline staff more fully into collaborative processes and consider the distinct roles administrators and care coordinators play in connecting organizations.

“Respite programs vary widely since no federal standard exists,” says Sanjukta Das Smith, PhD, associate professor of management science and systems in the UB School of Management. “We found that the most effective systems have partnerships that are built on strong relationships between administrators and frontline staff, and that regular, structured meetings are the glue that holds those relationships together.”

That foundation of trust and consistency becomes even more critical when extending collaboration across sectors.

“Without routine cross-sector communication and collaborative brainstorming, medical respite is difficult to sustain, says Sharon Hewner, PhD, professor in the UB School of Nursing. “There are many forces that push the housing and health sectors apart, but the urgent needs of persons experiencing homelessness and medical complexity demand we work together for solutions.”

According to Katia Noyes, PhD, professor and director of the Surgical Outcomes and Research Center in the UB School of Public Health and Health Professions, this research is about showing how sharing the right information quickly can make people healthier.

“We’re in a time as a society when, to improve health, you don’t necessarily need a new drug developed, she says. “Instead, you might need to find a faster way to share the right kind of information with appropriate provider. In other words, our study is testing how team science and data science can improve health.”

The study was conducted in partnership with Buffalo City Mission, Jericho Road Community Health Center and Spectrum Health and Human Services, and was supported by funding from the Robert Wood Johnson Foundation.