In most U.S. cities, terminally ill and medically frail homeless people have few housing options. In Salt Lake City, a nonprofit organization called The INN Between provides a home to those who don't have access to hospice or medical care simply because they lack housing. In a recent interview with Healthcare Innovation, Jillian Olmsted, the organization’s executive director, spoke about the growing need for its services and its partnerships with the healthcare community.
Healthcare Innovation: Could you just start by describing The INN Between’s origin story, and some of the services it provides?
Olmsted: The INN Between was an idea from a nurse at Huntsman Cancer Institute. She was finding it really discouraging when the hospital would say this individual is too well to stay in the hospital, but the nurse case managers were having a hard time discharging them out to the street because they were just too sick to go back out to the street. People who were needing hospice services needed an address and a caregiver as well to be able to receive those services. The same is true with home health. Some doctors won't even start cancer treatment plans if they assume that this person won't be successful in it, if they can't make those appointments or if they might lose their medications.
She started working with a group of individuals and created a think tank with some leaders of local churches and then started working closely with Fourth Street Clinic, which is a community clinic here in Salt Lake that serves predominantly homeless people. They decided to start their own 501c3 and got some support from the Catholic Diocese here and opened a small pilot program in a convent and elementary school that had recently moved out. I started volunteering shortly after it opened.
We quickly realized that it needed to be more than just providing a place for people to receive hospice care, and we expanded the program to also have a medical respite or recuperative care site where individuals can come in and have a short-term stay and heal that wound or get some sort of life-saving treatment or surgery and prevent them from becoming an end-of-life patient. About 15 to 20 percent of our program is hospice, and the rest is that medical respite or recuperative care where people are coming here, getting better, solving that acute condition and moving out of the facility.
HCI: Do some of those people that the medical respite has helped still end up homeless or is part of the work trying to find permanent housing for them?
Olmsted: The goal is to end their cycle of homelessness. The average stays are 70 days. That's a pretty tall ask to get someone to housing in that short period of time. We've developed some really good partnerships. There's another organization here called Switch Point and they have low-income housing and they can support the vulnerable population. We've worked with a lot of skilled nursing facilities that are willing to take our individuals on a long-term basis through a Medicaid nursing program, which works out really well. We've just finished the third quarter of this year and of the 130 people we've served, about 37 were discharged into a permanent housing space, which is really good. That number has increased a lot over the years. With our ability to expand and use this building to its full capacity, we’re hoping that we can keep people a little bit longer. Because there's always that kind of dance that we have to do: if this person seems well enough now they could make it in a resource center, while another person won't get a surgery if they don't get in here. But also that individual who's been here — if they could stay here for a little bit longer, maybe we can get them into something better than a resource center.
HCI: Is part of what you do case management to connect people with benefits like Medicaid or disability if they are eligible for those things?
Olmsted: Yes. We have someone coming in who can get people on Medicaid, if they're not already on it, and can switch them to a targeted adult Medicaid, which can help them with a housing supportive service that can get them their first month's deposit. We have a social services coordinator here. We meet with each individual when they first come in and we work on a goal plan. So we first want to know does that individual want housing? Do they want something different? Because some people don’t. It is rare, but some people have been chronically homeless, and they can't see anything different for themselves and they're not willing to work on anything different. But depending on what they're interested in, then we work on that while they are here. And we try to reduce all the barriers they have. So if they don't have their birth certificate, ID or Social Security card, we can get them those things. With insurance, we want to make sure that they can get care once they've left here. And we work through any of the barriers that they have. It can even be reconnecting them with family members who might allow them to stay with them for a little while while they finish getting back on their feet.
HCI: I understand that Intermountain Health provide some charity hospice care to uninsured residents. Can you talk about that a little bit?
Olmsted: We've had an Intermountain hospice physician on our board since we opened and he's been instrumental in that partnership. Initially Intermountain would pay a contracted bed fee when they referred people to us. Then it switched to them supporting us through their foundational arm, and they've always been willing to provide charity care, whether it's hospice or home health. We run into a lot of difficulties with individuals who are undocumented. We will take undocumented individuals, but the only option for them for home health and hospice is through Intermountain.
We just had an individual who was showing signs of dementia and he was undocumented, so no long-term care facilities would take him. He was with us for three years, which is very abnormal, but there was no safe discharge for him. And Intermountain was helping provide care for him.
HCI: Did the height of the COVID pandemic make your work there incredibly stressful and more complicated?
Olmsted: I think that we were extremely lucky. We're one of the very rare facilities that did not have COVID outbreaks. We put in some pretty strict parameters, and we had anybody who could work from home working from home. The state had some restrictions as well. And we only had staff test positive for the first two years of COVID. We started lifting a lot of the restrictions after about a year and we actually had our first resident-to-resident outbreak in December of 2022.
We have 24/7 CNAs on the floor, and during COVID I think they realized that getting paid $13 to $15 an hour wasn't going to cut it if you had to be exposed to COVID constantly. We were finding that we were having to pay our CNAs way more to keep them and it was really difficult to compete with the for-profit organizations, but we were able to utilize the employee retention credit through the IRS, and that helped us recoup some of those costs, because we didn't lay anyone off and that allowed us to utilize that.
HCI: Are there similar organizations to this in other major metropolitan areas that you know of? And if so, do you network with them and share best practices of how to run an organization like this?
Olmsted: We’re pretty unique in that we have a large facility and we do end-of-life care and medical respite and also have all these wraparound services. We just had a visit from some individuals at Joshua's House in California. They’ve been trying to open for several years. Part of it has been neighborhood upset, but that will be a 15-bed hospice facility for homeless individuals. They will actually be the hospice, though, whereas we've found it's a cost-saving model for us to utilize hospice organizations to come in and provide the care. The model that you will find throughout the U.S. is a 10-bed facility, oftentimes houses that are converted and run by just a couple of people and several of them are volunteer-run.
We do try to network a lot. I went up to Canada to visit a hospice for the homeless up there and it was interesting how different it was. It was very clinical. We try to keep our facility very home-like. We’ve found that many individuals don't like institutions — whether they've been in hospitals or shelters or prisons. It can be really difficult if things seem institutional.
HCI: Where do most of the referrals to your organization come from? Are they from hospitals and clinics or from the police?
Olmsted: Predominantly, it is the hospitals and that's because they are the most motivated to get their beds open quickly. Volunteers of America and Fourth Street have caseworkers and street outreach, so they can refer people to us as well. For us to take people in, it needs to be a medical referral. So someone on the street themselves could even call us and say I need to stay there. However, they would need to go to Fourth Street Clinic or an emergency department and get a referral from a doctor.
HCI: What are your major sources of funding? Are you getting money from Medicaid?
Olmsted: No, we're not. So we're predominantly doing grant-writing. Some of that comes through government or private foundations, and individual donations as well. We did work to pass a 1115 medical respite waiver, which eventually will allow us to bill insurance for medical respite at what we hope is a daily rate. It has not been approved for the federal portion of it through the Center for Medicare and Medicaid Services yet. We might be seeing that come through at the beginning of next year. But that would at best pay about half of our budget. So we are looking to get an ongoing state appropriation. That would be a big goal for us. We feel there's a lot of cost savings for the state, city and county, so we're hoping that we don't have to operate on a year-by-year fund-raising basis. We can have Medicaid and some ongoing state funding and then we would just have a small portion that we're fund-raising through our larger grants and not having dozens and dozens of $5,000 to $10,000 grants that were relying on.
HCI: Is there anything else about your work that I haven't asked about that you'd want to stress?
Olmsted: We like to touch on the fact that if we didn't exist here in Salt Lake, these individuals would be suffering and dying on the streets. The shelters are already overfilled, and depending on the day, there's a shortage of 300, 400, or 500 beds. We're not only giving a place for these individuals to receive dignified care, but we're hopefully helping reduce the costs on emergency medical services and hospitals. When people have these medical respite stays, their outcomes are so much better. They have less usage of the emergency room, and they typically don't keep going through that same cycle of wounds not healing or their cancer coming back.
