Various groups, clinics and organizations have set up places for homeless people to recover from injury, surgery or serious illness.
EEarlier this year, a homeless woman in her 40s who was living in her car checked into the emergency room of a hospital in Orange County, California. She was found to have stage 2 ovarian cancer. Since she had no home to return to after discharge, the hospital referred her to the Illumination Foundation, a non-profit housing organization. lucrative.
Foundation staff assessed the woman’s needs and admitted her to its 150-bed homeless recovery care center in Fullerton, Orange County. The woman’s Medicaid health plan covered the cost. Staff put her in touch with a primary care doctor and an oncologist to arrange chemotherapy. She is now receiving treatment and her condition is stable. She will remain in convalescent care while staff work to find her permanent home, according to Pooja Bhalla, DNP, co-CEO of the foundation.
Every night in the United States, approximately 580,000 people are homeless. If they are injured or recovering from surgery or serious illness, they have no safe place to recuperate. As a stopgap measure, hospitals and clinics sometimes give recovering patients a public transit pass to use all day or tell them to rest at a public library. Homeless patients often return to the hospital emergency department or are readmitted to hospital. Health outcomes are worse than for patients who have housing and medical expenses are higher.
In response, community health centers, homeless shelters, hospitals and other organizations have launched 133 medical respite programs, like the one used by the Orange County woman, for homeless people in 35 States and the District of Columbia, and others are starting up. , according to Barbara DiPietro, Ph.D., senior director of policy at the National Health Care for the Homeless Council.
There is no one way to operate a respite program. Some programs, especially those affiliated with hospitals and clinics, are staffed by licensed medical professionals. Others use unlicensed staff and rely on doctors, nurses and therapists to provide care. Many only accept patients who can perform activities of daily living on their own and who do not have serious mental illness.
“We think the value is really obvious, from the perspective of avoiding readmissions, providing better care, and giving people the opportunity to recover,” says Leanne Berge, CEO of Community Health Plan of Washington in Seattle, a not-for-profit insurer that administers Medicaid and Medicare Advantage managed care plans.
But there are far too few of these programs to serve all homeless people across the country who need housing and support while recovering. A number of factors limit their growth, experts say. It’s a cumbersome process for Medicaid plans to get state approval to cover these services, and many plans still don’t pay for it. Starting a medical respite program requires the cooperation of a variety of community stakeholders, including neighborhood residents, and it can be difficult. Moreover, there is not yet strong national data showing that these programs produce overall cost savings and better outcomes. A review of the literature published in 2021 by the National Institute for Medical Respite Care, however, found that without respite care, homeless patients have longer hospital stays and suboptimal outcomes, and that respite care resulted in cost savings for hospitals.
“It’s complex, time-consuming, and requires careful thought about how to work with partners,” says Karen Dale, CEO of AmeriHealth Caritas District of Columbia, whose plan helped launch a medical respite program called Hope Has a Home in Washington, DC, in 2019. Another hurdle, she says, is that Medicaid plans “are concerned that if they invest and do all this work and the person is no longer member, someone else benefits”.
On top of that, 12 states have yet to expand Medicaid under the Affordable Care Act, making it much more difficult for homeless respite programs in those states to fund their services because Medicaid is the main source of coverage for homeless people.
Because Tennessee hasn’t expanded Medicaid, “people in our homeless community are using the emergency room as their primary care provider, which drives up costs,” says Julia Sutherland, executive director of The Village at Glencliff, a medical respite program for the homeless near Nashville. . “That means we spend hours sitting with our people in the emergency room when we might be helping them find housing, benefits and jobs or taking them to the eye doctor.”
Lacking reimbursement from Medicaid, its program relies on support from a sponsoring church and contracts with local hospitals to serve their discharged patients in 12 single-family homes in the church’s former parking lot. But the lack of coverage makes it very difficult for participants to enter drug treatment. “It’s a hard thing to tell someone who wants help that they’ll have to wait,” Sutherland said.
light the way
Illumination launched its medical respite program for the homeless 12 years ago when leaders of local Orange County hospitals realized they needed a safe place to discharge homeless people, Bhalla says. . They asked Illumination to start a program.
The foundation built a 150-bed facility in Fullerton with an affiliated medical office upstairs staffed by physicians, including psychiatrists and nurses. He also established a 50-bed stand-alone facility in Riverside County and supports recovery care at Los Angeles County motels.
Prompted by the California Advancing and Innovating Medi-Cal program, a number of Medicaid plans have agreed to reimburse the foundation for the housing, case management, and behavioral health and substance abuse treatment it provides. They see evidence that the program improves enrollee outcomes and reduces costs.
For example, annual emergency room visits by homeless people enrolled in the CalOptima health plan fell 22% and hospitalizations fell 26% one year after Illumination services ended, according to a study conducted by Illumination in partnership with Cal Optima. Total costs per member per month decreased by 23%.
While some Medicaid plans such as CalOptima quickly approve enrollees for coverage in the foundation’s respite program, others are stingy with approvals, especially in Los Angeles County, Bhalla says. “Our beds sit empty because these plans don’t refer patients,” she said. “So hospitals have patients coming to the emergency room who don’t need to be admitted.”
At least seven medical respite programs in five states currently receive payment from Medicaid plans, and at least three states — California, Utah and Washington — are considering having their Medicaid programs cover it as a standard benefit, explains Di Pietro.
Medicaid plans reimburse respite programs in different ways. Yakima Neighborhood Health Services, a federally licensed health center in Washington that launched a respite program in 2010, receives a daily fee with an annual cap per patient from a plan, CEO Rhonda Hauff said. . Two other plans pay a case rate with an annual cap or a two-year cap per patient, she says.
The average cost of respite care at the Yakima Program’s two five-bed facilities is $140 to $160 per day, not including primary care and behavioral care provided at clinics. Add them up and the total is $350 to $400 per day. Three of the four Medicaid plans serving the Yakima area of central Washington have voluntarily agreed to cover the services. “The state is pushing (Medicaid plans) to get people out of hospitals,” Berge notes. “It makes so much sense to develop these alternative settings.”
Hauff has found that medical respite can serve as an entry point for homeless people who previously refused medical and behavioral care, shelter, and other services. “It’s often the most vulnerable time in their lives, when they feel particularly fragile,” she says. “When they start to feel better, they turn to our staff to help them find stable housing, employment, clothing and benefits like disability. This is the path to healing. A major problem for his program and others, however, is that permanent housing is scarce and many clients return to the streets or to a shelter. “If we kept everyone there until housing became available, we wouldn’t have enough surge capacity to help people recover from their acute condition,” Hauff says.
AmeriHealth Caritas DC adopted the medical respite approach after the Washington, DC, Medicaid agency moved in 2016 to pay-for-performance contracts that penalize plans for excessive hospital readmissions and emergency room visits. But Dale says the effort was primarily driven by a desire to improve health care and reduce disparities for DC’s poor.
Since opening, Hope Has a Home has served 161 male patients referred by local hospitals at its two eight-bed facilities, Dale says, including enrollees in all three Medicaid plans in DC A preliminary study found AmeriHealth Caritas collected a 19% return on investment through reductions in avoidable hospitalizations, all-cause readmissions within 30 days, and mild emergency room visits. Dale says her goal now is to open additional facilities for women, including pregnant women.
“Medical respite is an excellent solution for acting on the social determinants of health,” she comments. “It should be explored by more insurers to expand the healthcare delivery system in many places.”
Harris Meyer is a freelance journalist in Chicago who covers health care.
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