Shel­ter for con­va­les­cence

Hos­pi­tals link with respite pro­grams to aid home­less pa­tients through re­cov­ery

Modern Healthcare - - NEWS - By Steven Ross John­son

Dur­ing the past 20 years, Navy vet­eran Richard Kyle has been liv­ing pe­ri­od­i­cally on the street in Chicago be­cause of drug and al­co­hol ad­dic­tion. Last year, he was di­ag­nosed with lung cancer. Af­ter an in­pa­tient stay last­ing more than two months at the Ed­ward Hines Jr. VA Hospi­tal in the western sub­urbs, he be­gan out­pa­tient chemo­ther­apy treat­ments in Au­gust. In Novem­ber, af­ter a treat­ment ses­sion, Kyle, 60, who uses a walker, was un­able to find trans­porta­tion back to his tem­po­rary hous­ing in Chicago be­cause a snow­storm hit. “That’s one of the worst feel­ings, to be stranded,” he said.

Kyle called In­ter­faith House, a tem­po­rary res­i­den­tial fa­cil­ity on the city’s West Side, which paid for a taxi to pick him up and bring him to the shel­ter. Since then, Kyle has re­ceived meals and shel­ter at the 64-bed fa­cil­ity, where staff pro­vides him with trans­porta­tion to his med­i­cal ap­point­ments and makes sure he takes his med­i­ca­tions. He says the peace of mind of hav­ing re­li­able shel­ter and three meals a day has aided his treat­ment and re­cov­ery from cancer.

Med­i­cal respite pro­grams such as the one at In­ter­faith House—not-for-profit pro­grams that re­ceive fund­ing from hos­pi­tals, govern­ment grants and pri­vate do­na­tions—seek to ad­dress the prob­lems home­less pa­tients and health­care providers face when those pa­tients leave the hospi­tal. Tra­di­tion­ally, hos­pi­tals have dis­charged home­less pa­tients back onto the street only to have them make re­peated trips back to the emer­gency depart­ment be­cause they were un­able to man­age their own re­cov­ery. Pro­vid­ing care for home­less pa­tients, many of whom can suf­fer from com­plex con­di­tions, is of­ten very ex­pen­sive. Many tra­di­tion­ally have been unin­sured, par­tic­u­larly be­fore the ex­pan­sion of Med­i­caid un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

Na­tion­ally, there are cur­rently about 65 med­i­cal respite care pro­grams, also known as re­cu­per­a­tive care, op­er­at­ing across 26 states and the District of Columbia. Pro­grams op­er­ate out of a va­ri­ety of lo­ca­tions, in­clud­ing mo­tels, apart­ments, nurs­ing fa­cil­i­ties, home­less shel­ters, and tran­si­tional hous­ing fa­cil­i­ties. Cal­i­for­nia has the largest num­ber of respite care pro­grams, with 17.

With health­care providers fac­ing height­ened pres­sure to co­or­di­nate care and re­duce costs for pa­tients with chronic con­di­tions, some hos­pi­tals are ex­plor­ing part­ner­ships with pro­grams such as In­ter­faith to serve their home­less pa­tients for short pe­ri­ods af­ter their dis­charge from the hospi­tal. Other hospi­tal sys­tems and lo­cal govern­ment agencies, such as the Hen­nepin County Med­i­cal Cen­ter in Minneapolis and the New York City Health and Hos­pi­tals Corp., are pay­ing for longer-term hous­ing for home­less people with chronic ail­ments.

“Right now we see a huge gap in our health­care sys­tem,” said Sab­rina Edg­ing­ton, pro­gram and pol­icy specialist for the Na­tional Health Care for the Home­less Coun­cil, a not-for profit based in Nashville. “If you don’t have a home, you’re re­ally kind of in a nowhere land.”

On a sin­gle night in 2013, there were more than 600,000 people home­less in the U.S., ac­cord­ing to the U.S. Depart­ment of Hous­ing and Ur­ban De­vel­op­ment’s an­nual home­less as­sess­ment re­port to Congress. Of that num­ber, an es­ti­mated 35% lived in un­shel­tered lo­ca­tions. It is not known how many of the home­less are hos­pi­tal­ized an­nu­ally, but nearly 1,200 fed­er­ally qual­i­fied com­mu­nity health cen­ters in 2012 pro­vided care for more than 1.1 mil­lion home­less pa­tients, a 6.6% in­crease over 2011, ac­cord­ing to federal data.

Home­less pa­tients use hos­pi­tals at a much higher rate than housed pa­tients, stud­ies have found. A 2010 study found about 23 hos­pi­tal­iza­tions

On a sin­gle night in 2013, there were more than 600,000 people home­less in the U.S., ac­cord­ing to the U.S. Depart­ment of Hous­ing and Ur­ban De­vel­op­ment’s an­nual home­less as­sess­ment re­port to Congress.

In Cal­i­for­nia, the push for med­i­cal respite pro­grams was prompted by na­tion­ally re­ported in­ci­dents in Los Angeles of home­less pa­tients be­ing dumped in the Skid Row area by lo­cal hos­pi­tals be­cause they could not pay for care.

for ev­ery 100 home­less people in a year, com­pared with five hos­pi­tal­iza­tions for ev­ery 100 people in the gen­eral pop­u­la­tion. The aver­age costs as­so­ci­ated with a hos­pi­tal­iza­tion for a home­less pa­tient were $2,559 more than for a pa­tient who was housed, to­tal­ing about $13,500 for the aver­age stay. The aver­age hospi­tal stay for home­less pa­tients was four days longer on aver­age.

Some Med­i­caid pro­grams, such as the San Fran­cisco Health Plan, are pro­vid­ing longer-term hous­ing for home­less Med­i­caid en­rollees. But there is ev­i­dence that even short­term med­i­cal respite pro­grams can re­duce hos­pi­tal­iza­tions among home­less pa­tients. A 2009 study in the Jour­nal of Preven­tion and In­ter­ven­tion in the Com­mu­nity found that pa­tients served by med­i­cal respite pro­grams were 50% less likely to be read­mit­ted to a hospi­tal within 90 days af­ter dis­charge com­pared with those who go di­rectly back onto the street.

Fund­ing is a ma­jor chal­lenge for respite pro­grams, though the Af­ford­able Care Act and its op­tional ex­pan­sion of Med­i­caid cov­er­age to adults with in­comes up to 138% of the federal poverty level may of­fer some sup­port. States ex­pand­ing their Med­i­caid pro- grams gen­er­ally have en­cour­aged Med­i­caid man­aged-care plans and providers to of­fer flex­i­ble ser­vices in­clud­ing hous­ing and so­cial ser­vices sup­port that help chron­i­cally ill pa­tients man­age their health. States also can ap­ply for federal fund­ing un­der Med­i­caid Sec­tion 1115 demon­stra­tion waivers for home- and com­mu­ni­ty­based ser­vices, which per­mits pro­vi­sion of ser­vices to tar­geted pop­u­la­tions in non-med­i­cal set­tings in the com­mu­nity. That could in­clude fund­ing for med­i­cal respite ser­vices.

Some Med­i­caid man­aged-care plans, such as Aetna Med­i­caid, which op­er­ates Med­i­caid man­aged-care plans in 15 states, are look­ing at the med­i­cal respite op­tion. “Aetna Med­i­caid con­tin­u­ally eval­u­ates op­por­tu­ni­ties to cre­ate in­no­va­tive mod­els of care, such as join­ing with com­mu­nity-based or­ga­ni­za­tions in ef­forts to help the home­less re­cu­per­ate af­ter surgery,” said Pamela Sed­mak, CEO of Aetna Med­i­caid.

In Cal­i­for­nia, the push for med­i­cal respite pro­grams was prompted by na­tion­ally re­ported in­ci­dents in Los Angeles of home­less pa­tients be­ing dumped in the Skid Row area by lo­cal hos­pi­tals be­cause they could not pay for care. In 2008, the city passed an or­di­nance mak­ing it il­le­gal for hos­pi­tals to dis­charge pa­tients in that man­ner. That raised the is­sue of how Los Angeles hos­pi­tals should han­dle the dis­charge of home­less pa­tients once they were well enough to leave.

Out of that de­bate, 17 med­i­cal respite pro­grams have de­vel­oped. Most op­er­ate in South­ern Cal­i­for­nia, where pro­grams such as the one run jointly by the Na­tional Health Foun­da­tion and the Il­lu­mi­na­tion Foun­da­tion, called Re­cu­per­a­tive Care Cen­ters, have been treat­ing home­less pa­tients re­ferred by area hos­pi­tals. Un­like other med­i­cal respite care pro­grams, the Re­cu­per­a­tive Care Cen­ter model has fo­cused on get­ting mul­ti­ple health­care providers to par­tic­i­pate to make the pro­gram fi­nan­cially self­sus­tain­ing, said J. Eu­gene Grigsby III, CEO of the Na­tional Health Foun­da­tion.

Since 2010, Re­cu­per­a­tive Care Cen­ters in Los Angeles and Or­ange coun­ties have treated more than 1,500 home­less pa­tients at a sav­ings to hos­pi­tals of more than $12 mil­lion, Grigsby said. More than 20 health­care providers in Los Angeles County and 23 in Or­ange County par­tic­i­pate. Pa­tients are placed in mo­tels to con­tinue their re­cov­ery, with an aver­age length of stay of about 10 to 12 days. At a to­tal cost of $250 a day, hos­pi­tals spend about one-tenth of what they would have paid daily to house a home­less pa­tient at their fa­cil­ity. Like In­ter­faith, Re­cu­per­a­tive Care Cen­ters pro­vide sup­port­ive so­cial ser­vices with the goal of help­ing pa­tients tran­si­tion into per­ma­nent hous­ing.

The San Fran­cisco Depart­ment of Pub­lic Health’s Med­i­cal Respite and Sober­ing Cen­ter, a tax-funded pro­gram, opened in 2007, re­ceives 300 to 400 clients a year. Eighty per­cent come from San Fran­cisco Gen­eral Hospi­tal. Of the two-thirds of pa­tients at the cen­ter who com­plete their re­cov­ery with the help of the med­i­cal pro­fes­sional staff, up to 40% tran­si­tion into per­ma­nent hous­ing, said pro­gram di­rec­tor Tae-Wol Stan­ley. ED vis­its and read­mis­sions to the hospi­tal have de­clined

as a re­sult of the med­i­cal respite pro­gram, said Alice Moughamian, nurse man­ager for the cen­ter.

“People re­ally ap­pre­ci­ate it on the hospi­tal side,” Stan­ley said. “It gives the dis­charg­ing teams a safe and ef­fi­cient op­tion for these very vul­ner­a­ble and very costly clients.”

In Chicago, North­west­ern Me­mo­rial Hospi­tal works with In­ter­faith House for its pa­tients who are home­less. In Jan­uary, the hospi­tal be­gan con­tract­ing with In­ter­faith to pro­vide two beds to home­less pa­tients dis­charged from their fa­cil­ity. Jes­sica Soos Pawlowski, pa­tient-care man­ager at the 885-bed hospi­tal, said her fa­cil­ity treats about 100 home­less pa­tients on aver­age per month, many of whom would ben­e­fit from med­i­cal respite ser­vices. But it’s hard to find place­ments for them be­cause home­less shel­ters are usu­ally full and have lengthy wait lists. In ad­di­tion, In­ter­faith pro­vides ser­vices that go be­yond those that most home­less shel­ters of­fer, with over­sight by health pro­fes­sion­als.

Pawlowski es­ti­mates it costs North­west­ern about $500,000 a year to treat its pa­tients who are home­less, and ex­pects the con­tract with In­ter­faith to save the hospi­tal about $100,000 in the first year. “This part­ner­ship helps bet­ter man­age and se­cure the right care set­ting for longert­erm heal­ing,” she said.

In­ter­faith’s As­sess­ment/ Respite pro­gram re­ceives more than half its fund­ing from the U.S. Depart­ment of Hous­ing and Ur­ban De­vel­op­ment. Once there, pa­tients are as­signed a case man­ager who pro­vides med­i­cal over­sight. A clin­i­cian as­sesses and mon­i­tors their con­di­tion, makes sure they are com­ply­ing with med­i­cal or­ders, and pro­vides ba­sic med­i­cal care, such as wound treat­ment, when needed. Case man­agers also help pa­tients find a pri­mary-care physi­cian, ap­ply for Med­i­caid, and get coun­sel­ing for is­sues in­volv­ing be­hav­ioral dis­or­ders and sub­stance abuse. The goal is to pre­pare them to tran­si­tion into sta­ble hous­ing.

While Chicago-area hos­pi­tals have re­ferred their home­less pa­tients to In­ter­faith for years, In­ter­faith only re­cently has be­gun talk­ing to hos­pi­tals about sign­ing con­tracts for its ser­vices. So far, North­west­ern is the only health sys­tem con­tract­ing with In­ter­faith, though talks with other hos­pi­tals have been promis­ing, said Jennifer Nel­son-Seals, ex­ec­u­tive di­rec­tor for In­ter­faith House. “Hos­pi­tals … are start­ing to lis­ten to us,” she said.

In At­lanta, Mercy Care Ser­vices, part of the St. Joseph Health Sys­tem, in 2008 launched its Re­cu­per­a­tive Care pro­gram, a 19-bed fa­cil­ity that op­er­ates out of a con­verted prison. Hos­pi­tals re­fer home­less pa­tients to Mercy Care, where they can fin­ish their re­cov­ery. Mark Meyer, ex­ec­u­tive vice

While Chicago-area hos­pi­tals have re­ferred their home­less pa­tients to In­ter­faith for years, In­ter­faith only re­cently has be­gun talk­ing to hos­pi­tals about sign­ing con­tracts for its ser­vices.

pres­i­dent and chief fi­nan­cial of­fi­cer of At­lanta’s Grady Health Sys­tem, es­ti­mated the pro­gram could save Grady Me­mo­rial Hospi­tal as much as $500,000 a year for each acute-care bed that was freed up and then filled with an in­sured pa­tient. “If you can get some­one some shel­ter, and pro­vide them with some care and three meals a day, then that will cer­tainly re­duce read­mis­sions to the hospi­tal,” he said.

Hos­pi­tals par­tic­i­pat­ing in ac­count­able care ar­range­ments will in­creas­ingly see the value in part­ner­ing with med­i­cal respite groups to con­trol the costs of serv­ing home­less pa­tients, said Mercy Care CEO Thomas An­drews. “I think slowly (hos­pi­tals) are start­ing to get the fact that they need to have re­la­tion­ships with pro­grams like this that do a good job of keep­ing people out of the hospi­tal,” An­drews said. “As they start tak­ing on risk for dif­fer­ent pop­u­la­tions, maybe we would see some op­por­tu­nity for them to con­tact us to pay us for this ser­vice.”

Med­i­cal respite pro­grams need that kind of sus­tain­able fi­nan­cial sup­port to keep go­ing, rather than one-time govern­ment or char­i­ta­ble grants, Nel­son-Seals said. And the federal and state gov­ern­ments need to see hous­ing sup­port as a key part of health­care re­form. “Hous­ing is health­care,” she said.

Navy vet­eran Richard Kyle, who is re­cov­er­ing from cancer, has re­ceived meals and shel­ter at In­ter­faith House. He says the peace of mind of hav­ing re­li­able shel­ter and three meals a day has aided his re­cov­ery .

MICHAEL A. MAR­COTTE In­ter­faith House seeks to ad­dress the prob­lems home­less pa­tients and health­care providers face when those pa­tients leave the hospi­tal.

Since 2010, Re­cu­per­a­tive Care Cen­ters in Los Angeles and Or­ange coun­ties have treated more than 1,500 home­less pa­tients at a sav­ings to hos­pi­tals of more than $12 mil­lion.

Many pa­tients from Cal­i­for­nia care cen­ters are placed in mo­tels to con­tinue their re­cov­ery.

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