Hos­pi­tals must ad­dress hous­ing in treat­ing the home­less

Modern Healthcare - - COMMENT - By Dr. Kelly Do­ran

The so­lu­tion to re­duc­ing their ER use, then, is not just to give them an al­ter­na­tive place to sleep. They need an end to their home­less­ness.

When I see peo­ple on the street who are home­less, my gaze quickly trav­els from their faces to their wrists. I of­ten no­tice some­thing un­usual: hospi­tal ID bands, some­times sev­eral, dec­o­rat­ing each arm, like white pa­per-plas­tic badges of honor.

As an emer­gency depart­ment physi­cian in New York City, this comes as no sur­prise. In my work I see a dis­pro­por­tion­ately large num­ber of pa­tients who are home­less.

On any given day, nearly 600,000 peo­ple are home­less across Amer­ica. A large co­hort of fre­quent ED users comes from their ranks. They ac­count for a dis­pro­por­tion­ate share of hospi­tal read­mis­sions. Many have pro­longed lengths of stay for each hos­pi­tal­iza­tion. Ad­dress­ing the prob­lem of home­less­ness is crit­i­cal to re­duc­ing health­care costs.

In New York City, the Depart­ment of Home­less Ser­vices asks hospi­tal EDs to vol­un­tar­ily count their home­less pa­tients for its an­nual sin­gle-night count, but few do. This year the Bronx Health and Hous­ing Con­sor­tium took its own count in eight Bronx hospi­tal EDs. They found 120 home­less peo­ple there, while on the same night the of­fi­cial city count iden­ti­fied only 69 home­less peo­ple on the streets of the Bronx.

It is of­ten as­sumed that home­less peo­ple use the ED just as a place to sleep. But re­search tells us they dis­pro­por­tion­ately suf­fer from phys­i­cal and be­hav­ioral health prob­lems, which drive their use of EDs.

The so­lu­tion to re­duc­ing their ED use, then, is not just to give them an al­ter­na­tive place to sleep. They need an end to their home­less­ness.

One ob­vi­ous so­lu­tion is to give peo­ple some type of home. The health­care sys­tem could and should be part of pro­vid­ing th­ese resources not just be­cause of the pro­found ef­fect of home­less­ness on our na­tion’s over­all health, but be­cause of its im­pact on the health­care sys­tem’s over­all costs.

Some might ar­gue that tack­ling home­less­ness is not the re­spon­si­bil­ity of the health­care sys­tem. Yet hous­ing is a crit­i­cal so­cial de­ter­mi­nant of health, along­side oth­ers such as avail­abil­ity of healthy food and safe neigh­bor­hoods. Home­less­ness leads to wors­en­ing of med­i­cal con­di­tions, in­creased risks of in­jury and, ul­ti­mately, early death.

Turn­ing a blind eye to th­ese so­cial is­sues is no longer fi­nan­cially re­spon­si­ble. Solv­ing the so­cial prob­lems of pa­tients such as home­less­ness will be key to suc­ceed­ing un­der pay­ment re­forms that re­ward qual­ity of care and pop­u­la­tion health rather than sim­ply pay­ing for quan­tity of care.

There are no­table ex­am­ples of health sys­tems through­out the coun­try ad­dress­ing this cri­sis. The U.S. Vet­er­ans Health Ad­min­is­tra­tion rou­tinely screens pa­tients for home­less­ness risk and con­nects them to sup­port­ive hous­ing ser­vices and other pro­grams.

In New York, Med­i­caid pays for sup­port­ive hous­ing for some high-cost pa­tients who are home­less, fi­nanced by sav­ings from other Med­i­caid re­forms. In other parts of the coun­try, hos­pi­tals have col­lab­o­rated with ser­vice providers to cre­ate med­i­cal respite pro­grams for peo­ple who are too sick to be on the streets or in shel­ters but don’t need to be in a hospi­tal. Some ac­count­able care or­ga­ni­za­tions and health plans are ex­plor­ing pro­grams for their home­less pa­tients, which in­clude con­nect­ing them to hous­ing.

A com­mon theme in th­ese ini­tia­tives is co­op­er­a­tion across tra­di­tional health and so­cial ser­vice si­los. HHS’ Of­fice of the As­sis­tant Sec­re­tary for Plan­ning and Eval­u­a­tion and the CMS re­leased guid­ance in 2014 and this year on us­ing Med­i­caid to pay for ser­vices in sup­port­ive hous­ing for peo­ple who are home­less. This might al­low lo­cal health­care providers al­ready in­volved to ex­pand their ef­forts or get new sys­tems in­volved.

In­stead of see­ing ED vis­its by home­less peo­ple as just an­other prob­lem to be solved, we should con­sider how hos­pi­tals, in­sur­ers and the health­care sys­tem more gen­er­ally can be part of the so­lu­tion. Each of the hospi­tal bands on the wrists of a per­son who is home­less rep­re­sents a fail­ure of the health­care sys­tem, a missed op­por­tu­nity to in­ter­vene on the as­pect of that per­son’s life—home­less­ness—that most strongly im­pacts his or her health.

In­ter­ested in submitting a Guest Ex­pert op-ed? View guide­lines at mod­ern­health­care.com/op-ed. Send drafts to As­sis­tant Man­ag­ing Editor David May at dmay@mod­ern­health­care.com.

Dr. Kelly Do­ran is an in­struc­tor in the de­part­ments of emer­gency medicine and pop­u­la­tion health at the NYU School of Medicine and a prac­tic­ing emer­gency physi­cian at Belle­vue Hospi­tal Cen­ter in New York.

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