For those homeless and sick, or suffering from substance abuse or mental health disorders, life is a constant struggle. They show up repeatedly in hospital emergency rooms only to return to the streets, where the day-to-day challenge to survive quickly overtakes any follow-up medical care plans.
According to the U.S. Department of Housing and Urban Development, 549,928 people are homeless in the U.S. on any given night, 32% in unsheltered locations. More than 77,000 are chronically homeless. Lacking basic resources and support networks, they are five times more likely than non-homeless folks to be admitted to a hospital inpatient unit and stay on average four days longer, at a cost of $2,000 to $4,000 a day.
With severe diabetes and substance abuse issues, Matthew (who asked that his last name not be used) was in and out of the hospital constantly. His last stay lasted 80 days. “He really hit his rock bottom and at that point he was able to change and participate in treatment,” says Joy Victorine, program manager for the Care Transitions program at St. Joseph Hospital in Humboldt County, California. By that point, Victorine’s team also had a chance to meet with Matthew several times and begin to build some trust.
He was placed in one of five respite beds that St. Joseph’s rented through a community partnership and provided him with follow-up medical and social services, including helping him pay for transitional housing and supporting him through AA meetings. That was in 2010. Today, St. Joseph’s has 15 respite beds.
A growing trend
Across the country, hospitals are stepping up to deal with homelessness and whittle down accompanying high medical utilization costs. Their efforts range from providing post-discharge respite care to residential case management to donating money to build new housing units for homeless and low-income individuals. Some, like St. Joseph’s, grow out of local grassroots efforts. Most, if not all, rely on strong community partnerships.
The Corporation for Supportive Housing, a national organization focused on the homeless, estimates healthcare systems have invested between $75 million and $100 million in projects its supports. A number of hospitals and health systems have approached the group wanting to know how they can get involved in supportive housing, CSH spokesman Robert Friant told Healthcare Dive via email.
In August, the American Hospital Association published a guide exploring the impact of housing on health with recommendations on how hospitals can assist.
While some hospitals have been tackling housing for years, Carol Wilkins, a consultant with Integrated Solutions for People and Places, thinks the current uptick in interest may have its roots in the Affordable Care Act. “For a long time, hospitals have met their community benefit obligations by providing uncompensated medical care to patients who are uninsured,” she told Healthcare Dive via email.
“With the implementation of the ACA, in states that opted to expand Medicaid eligibility there are now fewer people who are uninsured, although many low-income immigrant patients still don’t have coverage.”
That’s causing hospitals to think of other ways to use their community benefit dollars, she says. The other big driver is the shift to value-based purchasing. Hospitals are being incentivized to reduce avoidable utilization and focus on outpatient care where possible.
Housing With Dignity
In Sacramento, Dignity Health provides one-bedroom apartments as “stabilization units” for individuals who are experiencing chronic homelessness and have some type of disability. The 12-unit program, called Housing With Dignity, is funded through community health benefit dollars and helps the local Dignity hospitals meet their nonprofit obligations.
Funding for the program is currently around $350,000, a combination of community health benefit monies and a contribution from HealthNet, a local MediCal provider. Dignity’s other partner in the initiative is Lutheran Social Services, which provides intense case management for participants. Patients learn not just how to follow-up on medical care and how to find primary care or behavioral health services, but also how to pay rent and utility bills and what types of behaviors are acceptable in an apartment complex.
“We know that 12 units are not going to make a dent in homelessness, but I think we have to start somewhere,” says Ashley Brand, director of community health and outreach for Dignity Health’s Sacramento hospitals.
The program has made a small dent in utilization. In fiscal year 2017, Housing With Dignity served 13 individuals and saw inpatient utilization decrease by 52%. Total days spent in the hospital also dropped 52%, and there was a 55% reduction in ER use.
St. Joseph’s Health
St. Joseph’s venture in housing began with five beds on the lower level of a ‘clean and sober’ house. The hospital’s community benefit dollars paid for the beds and the public health center provided follow-up medical care. Several years later, a grant from the county Medicaid program allowed them to add a nurse and social work team.
Last year, St. Joseph’s expanded its respite program from five to 15 beds through a partnership with a local homeless advocate. The hospital pays a yearly amount for the building and insurance, screens potential candidates and provides clinical case management for residents during their stay. The homeless advocate provides 24-hour nonclinical staff. Funding for the Care Transitions staff — two nurses, a social worker and a health coach — comes out of the hospital’s operations budget.
The program usually runs about 50% full, Victorine says. The goal is to stabilize patients enough to move out of the program in 21 days, but longer stays occur if needed. Last year, before the expansion, St. Joseph’s tracked about 930 days served through the respite program. With the additional beds, utilization has increased by about 60%.
Through the program, St. Joseph’s estimates it saves about $600 per patient per day. Victorine calls that figure “really modest” and wagers it could be closer to $1,500. And its success rate with patients is good. About half of the homeless who go into respite move into transitional housing with assistance from the team.
Victorine has some advice for other hospitals wanting to do something about homelessness. “Think outside the box and know what you do well,” she says. “If you already have a program within your hospital that’s going well and you can partner with someone in the community who is also doing their piece well, it could be a really nice collaboration. There are a lot of ways to be creative in terms of being able to reduce your length of stay for some of your complex patients.”
It’s also a good idea to set parameters, says Brand, adding there will always be a challenges where there’s a greater need than can be met. Partnering early on with community clinics, in-home support and other outpatient services can also help to ensure patients get the care they need without having to return to the hospital, she adds.
“If the patient has stable housing and they’re able to access other services outside of the hospital walls, their overall hospital utilization does decrease,” Brand tells Healthcare Dive.