Buffalo City Mission

People experiencing homelessness have disproportionately high rates of chronic disease, behavioral health challenges, and substance use disorders, yet they face barriers to preventive care and treatment. They often cycle in and out of the hospital and incur high health care costs. Hospitals are financially penalized for not discharging medically cleared patients or for readmitting patients within 30 days of discharge.

This leads to patients being discharged back to the streets or to shelters where their health condition worsens, eventually leading to readmission. Medical respite centers provide a solution for homeless individuals who are eligible to be discharged from the hospital but still require health care services. In addition to transitional housing and medical care, individuals have access to wraparound services—such as medication management, care coordination, and counseling and wellness services—while they recuperate in a safe environment. Buffalo City Mission (BCM) has piloted Western New York’s first medical respite program for homeless individuals in recovery. In 2021, NYHealth awarded BCM a grant to continue piloting its medical respite center.

Under this grant, BCM continued to operate its medical respite unit with on-site primary care and behavioral health partners, providing patients with comprehensive primary care, social services, and transitional housing. Legal Aid attorneys, housing specialists, and health insurance enrollers were also available for assistance. After recuperating, patients transferred to BCM’s 30-day shelter program and then to its transitional housing program. With support from the Robert Wood Johnson Foundation, BCM also partnered with a research team from the State University of New York at Buffalo’s Nursing School to conduct an evaluation and return-on-investment analysis. Based on results, BCM developed a full set of protocols for discharging homeless patients to medical respite care and laid the groundwork for the pilot’s sustainability and replication in other regions of the State.