Effectively Intervening with Patients Facing Housing Instability
By Dorothy Brooks
The notion that housing is healthcare stems from a growing body of research that links housing instability with higher rates of morbidity and mortality.1 “People who are experiencing chronic homelessness tend to be uninsured and are also hospitalized more frequently,” observes Catherine Mather, MA, a director at the Institute for Healthcare Improvement (IHI) who is overseeing a portfolio of projects that focus on improving care quality for people with complex health and social needs. “They are more likely to be readmitted, more likely to use expensive services, and all of this without seeing lasting benefits or improved outcomes to their health.”
There is a moral and humanitarian case for healthcare organizations to engage on the housing issue, but there also is a business case, according to Mather.
“This kind of thing is especially important right now ... as more providers and more health systems are moving away from fee-for-service [payment systems] and toward population health and value-based care,” she says.
But precisely how healthcare organizations should go about this work is not yet well established. Thus, IHI has partnered with Community Solutions, a nonprofit organization that is working to end homelessness, to examine how healthcare can play an effective role in addressing the problem.
Where do emergency providers fit into this work? “We can almost think of the ED as a bit of a bellwether for when a community’s needs are being met,” Mather says. “Anecdotally, we have heard from our teams that often it is the frontline ED providers who really know the people who are experiencing chronic homelessness in their communities, often by name. The challenge is often that ED providers don’t have too many options other than to discharge someone back on the street.”
Repeat ED Visits Are Likely
However, the reality is that when a person who is homeless is discharged in this manner, it is likely he or she soon will return to the ED. Mather says IHI and Community Solutions want to “build a better infrastructure for collaboration, and really disrupt that cycle by providing healthcare organizations, and then more specifically frontline providers, with system-level tools, structures, and resources to better serve those individuals who are experiencing chronic homelessness.”
IHI is working with Community Solutions and five participating sites on a pilot program addressing chronic homelessness. Every month, IHI gathers members from the five sites to provide individual coaching.
“We also come together a couple of times a year for workshops. We are really trying to support the individual learning at the pilot level, but also help [participating sites] learn from each other,” Mather says.
One of the participating sites is CommonSpirit Health’s CHI Memorial Hospital in Chattanooga, TN. Betsy Kammerdiener, market director for mission integration, says ending homelessness, especially with a focus on racial inequity, is very much a part of the hospital’s mission and values.
‘Grassroots’ Case Management
She notes that by working with partners in the region, the staff there are making progress toward what she refers to as a “grassroots case manager” approach that links the different healthcare providers and community resources through a case conferencing process.
This process was developed by the Chattanooga Regional Homeless Coalition. Today, the county medical center in the region, Erlanger Hospital, and CHI Memorial are linked into the case conferencing sessions as well so all the stakeholders can share information about current patients who are experiencing homelessness and want help.
If staff identify someone early enough in their hospital stay, a case manager can go into a case conference with other agencies. The group can discuss patient details, needs, and how they can help.
During this process, the group can discuss any paperwork or other information required for housing placement. The idea is by the time the patient is ready to leave, everything will be in order so he or she can be discharged successfully — typically to temporary housing. “From there, other agencies can come along with the permanent supportive housing if that is what is needed,” Kammerdiener says.
The case conferencing serves to involve all the relevant stakeholders in the process earlier. Conferencing also has helped familiarize hospital staff with the housing resources that are available in the community and the lingo housing experts use to discuss homelessness when they are working with government agencies. Further, it has helped hospital staff build relationships with the community organizations that work in the housing arena.
Ultimately, Kammerdiener would like to see this same sort of case conferencing process happen electronically so data are exchanged between hospitals, healthcare agencies, and other support services. This exchange could speed the process. “We need data-sharing, and we need more units of housing,” Kammerdiener says. “We do not have enough units of affordable housing here in Chattanooga. We do not have enough shelter space. There are some systematic gaps as well.”
One gap that has emerged is the need for medical respite. “If you have someone who would be eligible for home health ... but they have no home for home health workers to go to, what do you do with them?” Kammerdiener asks. “How can we create medical respite beds, and what kind of partnerships do we need to do that?”
CHI Memorial and its pilot partners are making progress. “We are working with three different agencies locally to help provide space and staffing for people who need this medical respite, but have no place to go,” Kammerdiener reports. “These are not nursing home patients, and they are not hospital patients, but they still need some support.”
One established form of medical respite housing is for cancer patients who might require daily trips to the hospital for radiation treatments and some help with activities of daily living, but they do not require inpatient care. Further, while patients remain in these medical respite beds, case managers can be working on more permanent housing solutions.
Angela Hanley, manager of the case management department at CHI Memorial, advises other health systems looking for ways to improve their engagement with patients faced with housing instability to place considerable focus on identifying these individuals as early as possible in their care encounters.
“As case managers, we don’t see every patient who comes into the hospital. There may be a patient experiencing homelessness, but we don’t know that they have any specific needs for case management to get involved,” she explains. “We’re trying to figure out a way to work with registration and our medical record system to clearly identify these patients so that [the system] will automatically send a referral to case management so we can be involved sooner.”
Hanley notes becoming involved at the time of discharge really limits how case managers can act. Early identification is a key step. “Also, just make sure you are connected with your [homelessness] experts in the community,” she says. “We need to make sure we are involving them early on so that we know what to do.”
The notion that housing is healthcare stems from a growing body of research that links housing instability with higher rates of morbidity and mortality. There is a moral and humanitarian case for healthcare organizations to engage on the housing issue, but there also is a business case. But precisely how healthcare organizations should go about this work is not yet well established. Thus, IHI has partnered with Community Solutions, a nonprofit organization that is working to end homelessness, to examine how healthcare can play an effective role in addressing the problem.
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