By Dorothy Brooks, Author
How does one ensure that a homeless patient takes his or her medicine or receives adequate follow-up for his or her chronic diseases following an ED visit? It’s a challenging problem, to say the least, and it is one that emergency providers in the United States confront on a daily basis. Now, some hospitals are stepping up their game in this area, adopting a “housing first” philosophy — or, the idea that having a roof over one’s head is inextricably linked with better health, and is a critical first step to any effective treatment plan.
Taking aim at what policymakers refer to as the “social determinants of health,” some of these programs are tiny compared to the scope of the homelessness problem in their communities. However, policymakers are giving frontline providers new options, drastically reducing use among formerly homeless participants. Further, in some cases, these new options are winning over new community partners willing to share the risk.
Assess Community Needs
The University of Illinois Hospital in Chicago initiated its “Better Health Through Housing” (BHH) program in 2015 following a community health needs assessment that revealed a high rate of chronic disease in the area.
“We were left to ponder what we were going to do about this,” explains Stephen Brown, MSW, LCSW, director of preventive emergency medicine at the University of Illinois Hospital and Health Sciences System in Chicago.
Brown has long been interested in how homelessness, serious mental illness, and substance use contribute to ED use.
“We felt [a housing program] could have a huge impact for the relatively small investment in dollars, and it has,” he says.
While the hospital pays $1,000 a month toward housing for each patient in the BHH program, that is significantly less than the per-day hospital expenditures for some of the homeless patients seen in the ED. Subsidies from the Department of Housing and Urban Development (HUD) also help cover housing for program clients, and case management services are provided through the Chicago Center for Housing and Health.
In a pilot of the BHH program, healthcare costs for program clients were reduced by a collective 18%, but in some cases the cost-savings were quite dramatic. Brown notes that one client’s average monthly costs dropped from $132,000 before program participation to $55,000 after enrolling in the program.
Eleven of the original 26 patients referred into the program in 2015 still reside in housing provided through BHH, and the University of Illinois Hospital recently announced that it will provide an additional $250,000 to the program — enough to provide permanent housing to an additional 25 chronically homeless ED patients.
Generally, potential candidates for the BHH program are identified by the number of times they have visited the ED in the past year. Patients who present to the ED more than eight times in a year are considered superusers.
“We start with that, and we begin to look at particular characteristics of these individuals,” Brown explains. “One of the key characteristics is they have to be chronically homeless,” meaning that the person has been homeless for at least one year or has experienced homelessness four times in the previous three years. The chronically homeless make up just 10% of the homeless population in the United States, but these individuals consume more than 50% of government dollars, Brown observes. A substantial portion of these dollars goes toward ED and hospital inpatient costs.
Cases that meet baseline criteria for the BHH program go before a chronically homeless referral panel (CHRP), a group that meets every two to three weeks to evaluate and select appropriate candidates for the housing program.
“We have a representative from our housing partner, The Center for Housing and Health, on the panel to make sure [candidates] meet criteria for the HUD subsidies that pay for part of [the housing],” Brown explains. Also on the panel are emergency and psychiatric physicians and social workers.
One of the critical factors the CHRP panel considers is the Level of Care Utilization System (LOCUS) score, a number derived from a tool designed to assess the care needed by individuals with psychiatric problems who present to EDs and other hospital settings. The LOCUS tool breaks down a person’s care needs into six levels, with persons at the highest level of need scoring 28 or higher.
“We have discovered that there are people who are so acutely psychotic that they are not appropriate for the type of housing we have because we don’t have the level of support necessary to keep them successfully retained,” Brown notes. “We have a cut off [LOCUS] score of 22, [which is the top score for level 4]. Anything below that is appropriate for referral into the BHH program.”
Other factors go into the evaluation process as well. For example, people who are undocumented are not excluded from the program, but entry is more challenging, Brown notes. Also, some people screened for the program have been sexual predators, which also is very challenging. “We need to also make sure that someone is not so acutely ill that they really need to be in a nursing home,” he says.
Once all the factors are assessed for an individual, the CHRP panel members will take a vote on whether the person is appropriate for the BHH program. If he or she is accepted, the hospital will begin an intake process, Brown explains.
At this point, an outreach worker who is skilled at finding and connecting with the homeless will be charged with locating the individual.
“He knows areas in the city where the homeless congregate — under bridges, in overgrown fields,” Brown says. “He knows the resources around those areas, so, for example, he will go to a soup kitchen that is open for a limited number of hours per week.”
In some cases, it takes time for the outreach worker to establish trust with an individual who has been deemed appropriate for the program.
“The most reluctant have serious mental illness and are withdrawn due to their symptoms,” Brown says. Some patients experience paranoia, auditory hallucinations, or have other issues that make social interaction difficult. “Also, those with the most serious substance abuse disorders have difficulty following through because of their frequent intoxication,” Brown adds.
While it can take one or even two months before some of these individuals accept the housing program, once they have given their consent, they are temporarily placed in a single occupancy hotel unit where they will be stabilized while the housing search takes place, a process that can generally be completed within a month.
“We have 125 to 150 units scattered around the city, and we work with our collective 28 area supportive housing agencies,” Brown shares. “Every one of the units comes with a permanent supportive case manager.”
While the program links patients with appropriate care resources, it is a misconception to think that simply connecting these patients with a primary care provider (PCP) will take care of their needs.
“By the time these people come to us, some of them have been chronically homeless for more than 10 years,” he says. “They generally have a lot of complex medical needs.”
The level of care required would overwhelm most PCPs, Brown notes. However, the supportive case manager will transition each patient’s care to centers or specialists that make the most sense, given their needs and the location of their permanent housing.
“The most important thing out of all of this is that ED utilization drops because [these individuals] no longer need to be in the ED anymore. They are not desperate to get out of the cold,” Brown says.
For example, one of the program’s success stories is a man with asthma and some mental illness who used to visit the ED 35 to 45 times per year.
“Sometimes, his asthma would be triggered because he was outside all the time,” Brown recalls. “We found him a place to live, and now he has great pride in his apartment.”
This patient’s use has dropped almost to zero, although he still comes into the ED once or twice a month just to see the nurses because they are his friends, Brown notes.
Secure ED Staff Buy-in
Now that the BHH program is well-established, ED personnel have become adept at making referrals.
“This has become a huge satisfier for our nurses, social workers, and doctors because they have been so frustrated with these individuals because they are so prevalent in our ED,” Brown says. “About half of our top 100 [users] are homeless, and a third of our top 300 [users] are homeless, so there is a great deal of frustration among our staff that these people keep coming in repeatedly.”
However, if one studies the behavior of these individuals, they are simply doing what anyone would in such dire circumstances, Brown observes. “Some of the people know how to gin up their symptoms and things like that because they have no other options.”
In fact, some people who wind up in the BHH program don’t even register when they come into the ED.
“They come in, and they sleep in our ED because we have a gap in the continuum of care here,” Brown notes. “The city has downsized the number of shelter beds for people with mental illness or substance use, and they haven’t offered up a plan to provide shelter for these vulnerable patients.”
The ED now employs an overnight social worker who makes connections with these individuals, and will present appropriate candidates to the CHRP panel. While social workers handle most of the presenting, psychiatrists, attending physicians, and hospitalists will present patients to the panel on occasion, too.
Given the impact of homelessness, food insecurity, and similar issues on health, it is curious that such factors are rarely mentioned in patient medical records, Brown observes. This is a reality that he and his staff are trying to change.
“You rarely see [these issues] documented at all, but our social workers are beginning to add [these items] to the problem list, and I am beginning to track compliance with doing [such] documentation,” Brown shares.
When it comes to homelessness, Brown is on a quest to convince healthcare providers that it is, in fact, a dangerous health condition.
“If someone comes in and has symptoms of a certain type of cancer, we will do everything we can, and it will be very expensive care for that individual,” he explains. “The irony of this is that we will discharge [a homeless] person back to the street, and the risk of mortality is comparable [to the person with cancer].”
Armed with such statistics, Brown is hoping to convince other hospitals to address homelessness as a matter of health, and he is getting some traction. Indeed, three hospitals in the region already have replicated the BHH program.
“If you think about it from a collective standpoint, if every hospital here in the city of Chicago decided to pay for housing for 10 chronically homeless individuals, we could reduce the number of chronically homeless people here in the city by 20% to 25%, and that is major impact,” he says. “And, it wouldn’t cost that much to do it.”
Brown also is working to engage managed care organizations on the issue, noting that they derive the greatest financial benefit from programs like BHH. He is proposing that they rebate some of the costs when the BHH program finds and houses chronically homeless individuals.
“A lot of these companies are open to the idea, so it is a way to do shared risk ... and we are making it painfully easy for them to do,” he explains.
To push forward on the housing issue, Brown and the University of Illinois Hospital are taking steps to better identify the number of homeless people living in the region. They’re working with All Chicago, a group that maintains a database of all of the homeless people in Chicago. Using a grant from Academy Health, the University of Illinois Hospital and All Chicago have developed a tool that will let ED staff know when a homeless patient has registered to be seen. Using this approach, Brown is hopeful that homeless patients can be identified and linked with care resources at an earlier stage, thereby improving the odds for better health outcomes.
“There is this emerging recognition that homelessness is a very dangerous health condition, and healthcare is trying to figure out how to respond,” Brown adds.
Dignity Health in Sacramento, CA, has partnered with Lutheran Social Services (LSS) of Northern California to offer a similar program, dubbed Housing with Dignity. In this case, most patients referred to the program are identified upon admission to one of Dignity Health’s hospitals in Sacramento.
“Our care coordination team starts working with them, and the patients are identified as being chronically homeless with a chronic disability,” explains Ashley Brand, the director of community health and outreach at Dignity Health. “Then, LSS will come to the hospital, meet with the patients, and make sure they are open to the services because the program is voluntary.”
Patients who consent to the program are discharged into what Brand refers to as stabilization apartments.
“It gets them [housed] with a roof over their heads with intensive wraparound services while LSS works to get them permanent, supportive housing,” Brand explains. “Sometimes, the units the patients are in for stabilization will actually become their permanent, supportive housing, but, technically, they move to a different program at that point. This provides some consistency for them, and enables them to build trust and build a home. That is ideal.”
Essentially, there are 12 stabilization units, but they move around based on what is available, Brand notes. “We really focus on the intensive, wraparound services that LSS has the expertise to provide so that patients are ready for the next step when the time comes,” Brand says. This includes getting the patients established with a medical home and plugged into behavioral health services. There also is a focus on equipping the patients with an ID and getting all of their documentation in place so that they can take advantage of more opportunities for stability as they move into permanent supportive housing.
Many different types of patients have come through the Housing with Dignity program, Brand says.
“We have had people who have been homeless for several years who have substance use disorders, and they may have been offered the program multiple times before they are ready,” she says. “By having that transition from the hospital to the stabilization unit, they are slowly able to [make a change].”
Some patients have been on the streets for so long that they may initially sleep on the porch or in the kitchen.
“They may put up their tent so that they feel some consistency with what they are used to,” she says. “One of the things that is great about the partnership with LSS is [their professionals] will move with the patient and meet them where they are at, and then work together to create goals as they move through the program.” The aim of the program is to help individuals feel empowered so that they can be their own self-advocates while there is someone to support their chosen direction, Brand notes.
“When we talk about the overall health and well-being of the community we serve, stable housing and supportive services are critical elements,” she says.
While Dignity Health has not yet conducted a full cost-benefit analysis of the program, administrators have studied the impact on use, and the results are impressive. In fiscal year 2017, the total number of days spent in the hospital by patients in the program decreased by 52%, and there was a 55% decrease in ED use. Brand stresses that the patients in the program tend to be very sick, but the program builds a relationship between LSS and the care coordinators at Dignity Health so that patients can be followed closely and kept on track with their care plan.
Brand’s advice to other hospitals that are just getting involved with addressing the housing component of health is to find a trusted partner who can work with them on the issue. “We worked very closely with LSS to build a program that is collaborative and impactful,” she says. “A lot of it is learning as you go, and being able to have iterations that respond to needs as they change.”
Knowing how your program works with the system in place in your region is critical because you don’t want clients to lose access to social services because their homeless status has changed, Brand notes.
“It is just one piece of a larger puzzle,” she says. “Work to understand the barriers that this population experiences, and really address the whole person.”