Nonprofit Finance Fund (NFF) spoke with the Sonoma County (CA) Department of Health and St. Joseph Health-Sonoma County about Project Nightingale, a partnership of local government, hospitals, and a local nonprofit that provides post-acute medical care for homeless individuals who are too ill or frail to recover from an illness on the streets.

This blog is the first installment in a series of interviews with partners in the Healthy Outcomes Initiative to highlight learnings, common challenges, and lessons learned when healthcare- and community-based organizations work together to improve health outcomes.

NFF: Tell us about the genesis of Project Nightingale. What was the motivation? How were the partners identified and what are their roles?

Jenny Symons, Sonoma County Department of Health Services

Sonoma County has a strong history of collaboration that has allowed cross-sector stakeholders to come together to improve the health of residents in our community. Project Nightingale and its need to be expanded bubbled up during a regular meeting of local healthcare providers that included the County and the heads of our three largest hospitals in Santa Rosa. Individuals experiencing homelessness have disproportionate rates of acute and chronic illnesses – which drives rates of hospital utilization by itself. In addition, a lack of housing for homeless patients in our community complicates discharge planning and subsequent recovery – which also leads to high rates of hospital readmission.

Catholic Charities of the Diocese of Santa Rosa started Project Nightingale in 2013 and was able to provide 13 respite beds for homeless patients after their discharge from the hospital. Respite beds provide a safe space for homeless patients who are too ill or frail to recover from a physical illness or injury on the streets, but are not ill enough to be in a hospital or skilled-nursing facility. By 2015, it became apparent that the program’s scale was being limited by a lack of funding for beds and constricting eligibility requirements; that the program was unable to prove impact and outcomes data under current data collection methods; and that splintered oversight from multiple funders was leading to an unsustainable long-term financing model.

Dan Schurman, St. Joseph Health – Sonoma County

High rates of homelessness in Sonoma County have posed a challenge for local health systems. High utilization of the emergency department and complex cases create a strain on the department and staff. There is a local coalition of hospitals that are competitors but also cooperate on projects. When Catholic Charities started Project Nightingale, we realized that by having the local hospital coalition pool our resources, we could not only increase the impact of the intervention, we could also invest in management and evaluation tools to better quantify the impact and return on investment. As a result, we can avoid unnecessary hospital stays, have lower readmissions rates, and have a direct savings to the hospitals

NFF: What outcomes are you measuring in the project? How will you know if it’s been successful?

Jenny Symons, Sonoma County Department of Health Services

We know that people will heal better from a wound or an illness if they have a clean and safe place, and time to rest rather than worrying about survival, so one of the short-term outcomes we are measuring is readmission to the ER or hospital for the same health issue. The long-term outcomes are focused on patients’ long-term health and disease management. We are also measuring the long-term effects of wraparound case management services that are offered through Project Nightingale, such as housing, and stronger connections to social services will help improve these clients’ overall health.

NFF: Part of the pilot is to take a broader look at innovative ways of financing health outcomes. How does this pilot work toward potential, sustainable financing/funding models?

Jenny Symons, Sonoma County Department of Health Services

Our “Capture and Reinvest” model looks at both the financial and societal benefits from the program. Through data collection and analysis, we want to prove that the program is working to improve health outcomes and also that we can measure its financial impact: who is saving money because of this program’s availability and its successful impact on its desired outcomes? For instance, the project is moving people out of hospitals and into respite care, which we know off the bat saves hospitals time and money. We also know that improving the long-term health outcomes of these high-cost patients saves insurance organizations money. Demonstrating improved health outcomes, as well as the long-term return on investment, through this pilot will allow us to approach other potential funders or investors and say, “If we can prove these outcomes, we’d like you to reinvest back into our pooled fund for future upstream intervention.” We have recently completed our “Capture and Reinvest Feasibility Study” on this project and our next step is to present the document to our stakeholders in May.

NFF: For this partnership to work effectively, what are the core investments required?

Jen Lewis, Sonoma County Department of Health Services

First off, we need to understand the full cost of achieving meeting outcomes across the partnership: What kind of data systems, support, and evaluation is required? Investing in the infrastructure to collect and share data is critical to tracking progress toward outcomes, engaging interested partners, and improving service delivery. Service provider readiness is also crucial. Do these service providers have the capacity to expand their programs and use data collection and evaluation tools to track and achieve the intended outcomes? Do we need to invest more into the service providers themselves to build up these capacities?

NFF: What advice do you have for other communities that, like Sonoma, want to address social determinants to improve community health?

Dan Schurman, St. Joseph Health – Sonoma County

Go broader than the health system and look to the community where you have established partnerships and trust from previous collaborations. Next, find a champion to leverage existing relationships and push the partnership forward. Healthcare systems can be complex and you need someone influencing the partners to ensure that agreements are complete and that data is shared.

Stay tuned for our next Learning Network webinar being held in July. To sign up for updates, please email health@nff.org.