Shelter for convalescence

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 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 short-term 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 programs 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 community-based 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 self-sustaining, 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 longer-term 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 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.

Follow Steven Ross Johnson on Twitter: @MHsjohnson