Taking It to the Streets: How Marshall is Working with Vulnerable Populations
It’s Tuesday afternoon at Upper Room Dining Hall in Placerville. Jim, a local man who is currently without a home or shelter, has come for a hot meal before he faces a night out in the cold. What’s different about this visit is that Shaunda Crane, RN, from Marshall Medical Center is there. Shaunda helps clients in the Upper Room with wound care assistance, a common condition for many homeless. Jim has an infected wound and appreciates instruction on how to care for himself. During their conversation, Jim is able to open up about some of his other health concerns. He’s also diabetic and is having trouble controlling his blood sugar on the street, which lands him in the ER on occasion for treatment. Shaunda is able to help him with this before he takes his dinner to go. She hopes to see him next week to check in with him and to talk to him about his goals for obtaining permanent or temporary housing.
This weekly check in at Upper Room is how Marshall’s Care Coordination for Vulnerable Populations program started. Conversations open up opportunities to discuss health issues and other challenges. Working closely with El Dorado County’s Homeless Outreach Team (HOT) and other assistance organizations, Shaunda expanded outreach efforts to include HOT’s Trailer Days, where people can get haircuts, laundry services, food, clothes and more, as well as regular check ins throughout the county to provide medical support. It encompasses many vulnerable populations, including unsheltered, elderly, at-risk women and the Latino community.
When the pandemic hit, Martin Entwistle, Executive Director of Population Health at Marshall, saw a need to help find services for the county’s most vulnerable. The effort dovetailed with Governor Gavin Newsom’s Project Roomkey, an executive order mandating California Health and Human Services Agency and Office of Emergency Services to make hotels available as temporary residences to quarantine and treat individuals who have tested positive for COVID-19. Many local organizations and agencies, including Health and Human Services, the El Dorado County Sheriff and Placerville Police Departments, the Public Health Department, and Community Health Center, as well as Snowline Hospice, Barton Hospital, Veteran’s Services and more are working together to coordinate the Navigation Program, a three- phased program to help address the needs of the homeless community. Phase one of the program is to address acute, immediate medical needs including wound care, mental health and addiction, blood sugar and blood pressure management. Phase two is Project Roomkey, where individuals who meet certain requirements are provided with temporary housing at a motel in Pollock Pines. Phase three is where people work on obtaining basic necessities in order to find a permanent home and employment, such as a driver’s license, social security card, food stamps, and a cell phone.
The program is goal-oriented, with each person provided a check list or care plan form to keep track of their tasks and to know what comes next. The program also teaches life skills in addition to addressing health issues that may be thwarting the ability to obtain safe, stable housing. It’s been so successful that other California counties look to El Dorado County as an example for their own programs.
In a related effort, Marshall has established the Multi-Visit Patient (MVP) Program to address utilization of health services in areas such as the Emergency Department (ED). This is a prime example of health services that are misused and over-used by the unsheltered, who tend to use the ED for primary care. Due to the stigma that surrounds homelessness, many are hesitant to visit a primary care provider out of fear of judgement so they wait until they’re very sick and end up in the ED. The goal of the MVP Program is to treat chronic health problems so they are more manageable and reduce some of the burden on the ED.
These are examples of the programs Marshall is taking part into assist and improve the health and wellbeing of the vulnerable. Marshall has a long tradition of collaborating with the community. Creating a culture of partnership with organizations has earned Marshall national recognition for civic leadership in addition to patient outcomes and value of care.
Conversations open up opportunities to discuss health issues and other challenges.
This weekly check in at Upper Room is how Marshall’s Care Coordination for Vulnerable Populations program started. Conversations open up opportunities to discuss health issues and other challenges. Working closely with El Dorado County’s Homeless Outreach Team (HOT) and other assistance organizations, Shaunda expanded outreach efforts to include HOT’s Trailer Days, where people can get haircuts, laundry services, food, clothes and more, as well as regular check ins throughout the county to provide medical support. It encompasses many vulnerable populations, including unsheltered, elderly, at-risk women and the Latino community.
When the pandemic hit, Martin Entwistle, Executive Director of Population Health at Marshall, saw a need to help find services for the county’s most vulnerable. The effort dovetailed with Governor Gavin Newsom’s Project Roomkey, an executive order mandating California Health and Human Services Agency and Office of Emergency Services to make hotels available as temporary residences to quarantine and treat individuals who have tested positive for COVID-19. Many local organizations and agencies, including Health and Human Services, the El Dorado County Sheriff and Placerville Police Departments, the Public Health Department, and Community Health Center, as well as Snowline Hospice, Barton Hospital, Veteran’s Services and more are working together to coordinate the Navigation Program, a three- phased program to help address the needs of the homeless community. Phase one of the program is to address acute, immediate medical needs including wound care, mental health and addiction, blood sugar and blood pressure management. Phase two is Project Roomkey, where individuals who meet certain requirements are provided with temporary housing at a motel in Pollock Pines. Phase three is where people work on obtaining basic necessities in order to find a permanent home and employment, such as a driver’s license, social security card, food stamps, and a cell phone.
When the pandemic hit, Martin Entwistle, Executive Director of Population Health at Marshall, saw a need to help find services for the county’s most vulnerable.
The program is goal-oriented, with each person provided a check list or care plan form to keep track of their tasks and to know what comes next. The program also teaches life skills in addition to addressing health issues that may be thwarting the ability to obtain safe, stable housing. It’s been so successful that other California counties look to El Dorado County as an example for their own programs.
The goal of the MVP Program is to treat chronic health problems so they are more manageable and reduce some of the burden on the ED.
In a related effort, Marshall has established the Multi-Visit Patient (MVP) Program to address utilization of health services in areas such as the Emergency Department (ED). This is a prime example of health services that are misused and over-used by the unsheltered, who tend to use the ED for primary care. Due to the stigma that surrounds homelessness, many are hesitant to visit a primary care provider out of fear of judgement so they wait until they’re very sick and end up in the ED. The goal of the MVP Program is to treat chronic health problems so they are more manageable and reduce some of the burden on the ED.
These are examples of the programs Marshall is taking part into assist and improve the health and wellbeing of the vulnerable.
These are examples of the programs Marshall is taking part into assist and improve the health and wellbeing of the vulnerable. Marshall has a long tradition of collaborating with the community. Creating a culture of partnership with organizations has earned Marshall national recognition for civic leadership in addition to patient outcomes and value of care.