Crossing Sectors Together: Forging a New Path Home for Medically Complex Chronically Homeless Patients

Buffalo’s wicked problem of lack of housing for medically complex chronically homeless patients leaving area hospitals is compounded by baseline poverty, poor health outcomes, and barriers to care.

This proposal seeks to establish the only medical respite unit in the region, supported by relational, evidence-based care transitions partnerships between interdisciplinary providers from the Buffalo City Mission, University at Buffalo School of Nursing, and Erie County Medical Center.

Once established, project stakeholders aim to launch a regional cross-sector collaborative network to better track, collaborate, and improve the outcomes of medically complex chronically homeless patients in our city and beyond. Through these achievements, we aim to reduce health care recidivism, increase transition to housing and self-management of chronic disease, and establish collaborative care networks for Buffalo’s sickest homeless citizens.