Providing Post-Hospital Care for Homeless Individuals in Tracy

At Tracy Community Connections Center (TCCC), we understand that healthcare doesn’t end at the hospital door. Many homeless individuals rely on the ER for basic medical care, only to face additional challenges once discharged. That’s why we’ve partnered with social workers at Sutter Hospital in Tracy to create a vital post-hospital care program, designed to support our most vulnerable neighbors and ease the burden on emergency services.

Addressing the Challenge of Post-Hospital Care

For homeless individuals, the transition from hospital to community can be daunting. Without a safe place to go, access to food, clothing, or even follow-up care, patients are at high risk of readmission. This cycle not only jeopardizes their well-being but also leads to increased healthcare costs and strain on emergency services. TCCC’s innovative approach tackles these challenges head-on, offering both short-term relief and long-term solutions.

How Our Program Works

Through our collaborative efforts with Sutter Hospital’s social workers, we ensure that qualifying individuals discharged from the ER in Tracy receive comprehensive support:

Safe Discharge

We develop a discharge plan for each client which may include emergency motel housing at the doctor’s discretion. Our team will work with the social workers, doctors, and the client to connect them to a primary care physician, coordinate case management, and develop a long-term housing solution.

Essential Supplies

We ensure that every client receives what they need, including discharge instructions, medications, clothing, and food.

Daily Support

Recognizing that recovery is a process, our team checks in on each client daily, offering ongoing case management and assistance – tailored to help them secure longer-term, stable housing.

Coordinated Care

We meet bi-weekly, or more frequently, with Sutter Hospital social workers to discuss each case and continuously improve the quality of care. This coordinated effort helps prevent readmissions and supports sustainable recovery.

Impact and Importance

In 2024 alone, our post-hospital care program helped 74 clients. Each of these individuals received not just immediate relief, but a pathway toward a more stable future. By providing comprehensive support right after hospital discharge, we:

Care for Individuals

Our program addresses the immediate needs of those transitioning from critical care, ensuring they have a safe environment to continue their recovery.

Prevent Readmissions

With proper follow-up care and daily check-ins, we reduce the likelihood of complications that can lead to re-hospitalization.

Reduce Healthcare Costs

By keeping individuals out of the ER and hospital, we help lower the overall healthcare costs associated with chronic, unmanaged conditions.

Break the Cycle

Ultimately, our approach not only supports immediate recovery but also paves the way for long-term stability and independence, breaking the cycle of homelessness and repeated ER visits.

Join Us in Making a Difference

The work we do at TCCC is driven by a simple belief: everyone deserves a safe, supportive environment to heal and thrive. Through our post-hospital care program, we are not only helping individuals recover but also contributing to a healthier, more compassionate community in Tracy.

If you’re interested in learning more about our program, volunteering, or supporting our mission, please get in touch. Together, we can build a community where everyone has the opportunity to reclaim their health and hope.