The San Francisco Health Plan, a Medicaid managed-care plan, working with the city's health department and a local development agency, will begin in December to house 50 homeless enrollees who most frequently end up in the hospital and emergency room.
The health plan's members will gain housing under an effort that will also provide homes for another 122 chronically ill, homeless individuals in San Francisco in a newly redeveloped nine-story building scheduled to open at the end of the year.
Dr. Kelly Pfeifer, chief medical officer for the San Francisco Health Plan, said a 2011 California mandate that shifted seniors and the disabled into Medicaid managed care increased the insurers' membership by 13,000, an influx that included many with chronic illnesses and an unknown number of homeless.
“It's difficult to know how many” because it can be difficult to collect the information, Pfeifer said, but the health plan began to scour medical records for patients who required the most medical care and found homelessness, mental illness and substance abuse were common.
Among newly enrolled health plan members, hospital visits were “unlike anything we've ever experienced before,” she said. For every 1,000 health plan members who are seniors or disabled, the health plan saw 157 days of hospital care a year, compared with 17 days for the health plan's other 55,000 members.
Pfeifer said the health plan has worked during the past year to identify strategies to keep patients out of the hospital by improving access to outpatient and primary care. “Hospitalization is a failure of the medical system,” she said. “It means that the condition has gotten so out of control that someone is at risk of life or limb.”
More support will be needed for homeless patients with behavioral health needs than for patients in existing care-management programs, such as those that pair nurses with seniors struggling with congestive heart failure. “We had not developed a lot of infrastructure for people with complex conditions,” Pfeifer said.
In recent months, the health plan has revamped its support program with help from a University of California at San Francisco physician and has started to find and contact patients.
A partner of the health plan, the Tenderloin Neighborhood Development Corp., received one of four grants from the Corporation for Supportive Housing to curb San Francisco's public health spending by increasing access to housing.
Dr. Josh Bamberger, the medical director for Housing and Urban Health at the San Francisco Department of Health, said New York University researchers will study whether healthcare spending changes for patients who gain housing and will evaluate how that spending compares to those who remain homeless. Bamberger said the study will build on prior research that has found a link between reduced healthcare costs and housing.
For example, Chicago patients enrolled in a 2003-07 study made 1.2 fewer emergency room visits and spent 2.7 fewer days in the hospital per year when provided with housing compared with those who received no housing support.
Bamberger, a family practice physician who was named this month as special adviser to the executive director of the U.S. Interagency Council on Homelessness, has long been an advocate for housing to address chronic diseases. “I think that providing healthcare for the homeless without housing is like shooting an elephant with a BB gun,” he said.
Money spent on housing improves health, he argues, so spend healthcare money on housing. “My point is that housing should be a healthcare intervention,” he said. “The etiology of chronic homelessness is not exclusively economic, it's predominantly medical.”
In Los Angeles County, 11 hospitals, six safety net clinics and more than a dozen housing and homeless agencies will begin in October to target housing and support services for 107 adults who rank among the costliest 10% for public spending, or $78,348 a year, on average, of which emergency room visits and hospital admissions count for half.
The effort will overlap with another initiative launched in the spring of 2011 that has found homes for a dozen patients and is seeking housing for another 14. It's too early to say how health spending has changed, said Susan Lee, a senior program manager for the Corporation for Supportive Housing, which provided grant funding for both initiatives.
Dr. Theresa Brehove, director of homeless services for the Venice (Calif.) Family Clinic, one of the half-dozen federally qualified health centers in both efforts, said housing alone cannot address conditions such as mental illness or substance abuse that commonly contribute to patients' homelessness, but a home gives patients stability that can improve medical care. Diabetics gain greater control over their diets. Nurses can make home visits. “Certainly, things like medication adherence is greatly improved when they have a place to stay and more of a routine and less chaotic life,” she said.