Giving shelter care: Some health systems serve the homeless where they stay

When Joe Ruth heard about a South Bend hospital operating a primary-care clinic inside a homeless center, the chief operating officer of four-hospital Lansing, Mich.-based Sparrow Health System and several colleagues hopped on an Indiana-bound bus to investigate.

The Central Neighborhood Health Center, run by the Beacon Medical Group unit of the two-hospital Beacon Health System, is housed in a three-story brick building not far from the hulking ruins of a former Studebaker auto plant. The Center for the Homeless, run for 26 years by a local not-for-profit, is in the same building.

“We walked through this clinic and we were shamed into doing something,” Ruth said. When they saw the difference the clinic was making in these people's lives, it kick-started “a communitywide effort to shine a light on our most vulnerable.”

It took a while, but community leaders eventually came together to tackle the problem. “We held some fundraisers. We got some federal money. And then we built this beautiful clinic,” he said. It opened in March 2014, four years after the initial bus trip.

The 6,500-square-foot Sparrow Medical Group-Volunteers of America Clinic was built in a century-old warehouse in downtown Lansing where Volunteers of America-Michigan runs a homeless shelter and support center. The project's cost was about $800,000. A lot of the architectural and excavation work was provided free or at cost. Sparrow allocated more than $300,000 to cover startup costs as part of its community benefit contribution to justify its tax-exempt status, Ruth said.

During its first year, the Lansing clinic had 4,200 patient visits, while the shelter housed nearly 1,700 people. “We deal with all family practice issues,” said

Dr. Lynn Nevin, whom Sparrow recruited to work full time at the clinic. “High blood pressure, tobacco cessation, substance abuse problems, diabetic foot care, EKGs, pulmonary functions, everything.”

Once the clinic was up and running, Ruth said the Lansing Fire Department called the shelter staff and asked if everything was OK. They were surprised because they hadn't had to send any ambulances to the homeless center in weeks. “They used to have one every day.”

The Lansing and South Bend clinics attached to homeless housing facilities represent fledgling efforts by healthcare providers and insurers to take a more holistic approach to health needs in the communities they serve, including addressing housing issues. That movement received a boost from the Affordable Care Act's Medicaid expansion to low-income adults, as well as the law's requirement that not-for-profit hospitals publicly report their community benefit programs to keep their tax-exempt status. It also may be fueled by the growing scrutiny not-for-profit providers and insurers are facing from state and local governments on whether they are providing enough charitable benefits to justify their tax exemptions.

More healthcare organizations are recognizing they need to address housing issues to manage the health of Medicaid and low-income members in order to reduce emergency department and hospital visits and succeed under value-based payment arrangements. For instance, UnitedHealthcare has contracted with homeless coalitions in Houston and Austin, Texas, to work with its Medicaid plan members who lack a stable place to live, helping those members find subsidized housing. Other hospital systems and public health 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.

“Housing is healthcare,” said Mark Trotz, who directs the Housing for Health program at the Los Angeles County Department of Health Services. “You can prescribe all the various medicines and all the other interventions in the world, but they don't add up to a hill of beans if you don't have housing.”

Still, public and private insurers have been leery about paying for housing needs. In 2013, the Obama administration rejected a request from the New York State Health Department for federal matching funds to help Medicaid enrollees pay for housing. That may change as health plans and providers receive global fees per member and gain greater flexibility in how to allocate funds to keep their enrolled populations healthy.

About 100 federally qualified community health centers have links to supportive housing projects around the country, with health systems involved in some but not all of them, said Bob Friant, a spokesman for the Corporation for Supportive Housing, which offers guidance and financial assistance to groups providing housing for the homeless across the country. There are no data on how many health systems are staffing or supporting homeless shelters or other transitional housing initiatives.

Friant said the ACA's Medicaid expansion and community benefit rules have encouraged healthcare providers and insurers to address housing for the homeless. “We're reaching out to hospitals, systems and managed-care organizations,” he said. They are “the new frontier for supportive housing.”

L.A.'s Housing for Health program oversees about 1,000 rent-subsidized housing units and plans to add 1,500 more in 2016, with a long-term goal of 10,000 units. Trotz's office is in the city's Skid Row neighborhood, in a building shared with 100 units of subsidized housing and a clinic with five exam rooms. His program opened the clinic a year ago. It serves the building's tenants and other homeless people in the neighborhood.

“There's just a huge amount of need for people living outside,” Trotz said. Homelessness leads to “really insane costs borne by the public health system treating (homeless people) in a way that doesn't work.” Those public costs include not only higher direct medical costs associated with delayed treatment or lack of treatment, but also costs associated with ambulance runs, police activity, courts and jails.

A 2009 study published in JAMA found that offering housing and case management to a population of homeless adults with chronic medical conditions resulted in 29% fewer hospital days and 24% fewer ED visits.

Trotz said Los Angeles County has commissioned a study by the RAND Corp. on the cost of subsidized housing for the formerly homeless versus healthcare costs for those without housing. But, after working with the homeless for more than two decades, Trotz already believes that subsidized housing programs pay off. He argues this is an effective approach for private health systems as well as public ones.

“It's not rocket science,” he said. “There are large reductions in visits to emergency rooms, the number of acute-care hospital days, lengths of stays. If you have a case manager you don't have to call 911 four times a week because you're out on the street.”

The Lansing clinic for the homeless serves only people who are connected with the adjacent Volunteers of America homeless housing and support program. There are no current plans to expand beyond that. “When we took this to our board of directors, we knew the numbers would never pencil out,” Ruth said. “We heavily subsidize this practice.”

In contrast, patients at the Central Neighborhood Health Center in South Bend don't need to be residents of the homeless center. The clinic handles 150 to 200 patients a week, who are served by a family physician, a nurse practitioner and a part-time pediatrician. Only 15% to 20% of clinic patients are staying at the center or living on the street, said Dr. Brandon Zabukovic, who works at the South Bend clinic. Like Michigan, Indiana expanded Medicaid to low-income adults, so many of the clinic's clients have a payment source.

Zabukovic is convinced the clinic-in-a-homeless center is a model that can be replicated by health systems across the country. “It fits the mission,” he said. “It's an access point that provides good quality care to a needy population.” And he notes that it helps keep healthcare spending down by reducing ED visits and hospitalizations for patients with serious chronic conditions.

“I wouldn't trade this for traditional suburban medicine for a million dollars,” Zabukovic said. “Patients here are so appreciative of having people taking care of them. I think we played a role in getting a lot of people graduated,” which he defines as helping clients get clean from substance abuse, housed, placed in a GED program and enabling them to move on with their lives.

At the Lansing clinic, half the patients Nevin sees have a mental health diagnosis. “There are a lot of problems, a lot of things going on,” she said. “You can't do an eight-minute visit. We'd like to see 20 visits per provider, but that can't always happen.”

The clinic and shelter help clients enroll in any benefit programs for which they are eligible, such as Michigan's Medicaid expansion program for low-income adults, called Healthy Michigan. That makes it easier to refer patients for tests and specialty care that aren't offered at the clinic. Volunteer attorneys help clients get disability benefits, which helps them get into long-term subsidized housing.

“It's beautiful to see people being able to obtain shelter,” Nevin said. “If you can get somebody a stable place to live, everything gets better.”

Patrick Patterson, executive vice president of Volunteers of America Michigan, said having the clinic in the same building as the shelter is critical to providing healthcare access to his clients.

What's still missing, Patterson said, is a full-time behavioral health clinician. A caseworker from the local community mental health center is embedded at the clinic five days a week and connects clients with mental health services. But the clinic needs a mental health professional who can diagnose, prescribe and do psychiatric evaluations for disability benefit determinations. “It's something we still badly need in terms of resources,” he said.

Joann Doby-Waters, who serves as the Lansing clinic's administrator, said nothing in her career “has given me this kind of fulfillment. Last week, one of my patients stopped me and told me how wonderful Dr. Nevin was, that she saved her life.” Another patient was so appreciative that he wrote a poem and gave it to Nevin. “You treat a lot of people with great respect, you're the type of person I never neglect,” the patient wrote.

“It's really, really touching to hear what happens,” Doby-Waters said. “I'm proud to be a part of this.”