With the ER the most expensive point-of-entry into the healthcare system, hospitals are pursuing a better way to manage chronically ill and homeless patients. From Baltimore to Denver to Sacramento, health systems are working with local housing authorities to develop residences for patients who can stay in their own place to be treated.
The cost for a month of such home-based care can easily equal the cost of keeping the same patient in the hospital via the ER for just one night. And, the solution addresses other social determinants of health (SDoH), such as hunger and economic hardship, that impact most of health outcomes.
“Being homeless is hard on the body … and if you have a chronic medical condition, it’s only going to exacerbate it,” according to Stephen Brown, Director of Emergency Medicine at the University of Illinois in an interview earlier this year with the local PBS station. “We also found some individuals that were just coming for what we call ‘secondary gain,’ and their health care costs plummeted because they had no reason to seek out shelter in emergency departments any longer.”
Keeping Patients in a Home Setting Reduces Healthcare Costs
Hospitals are getting into the housing sector as part of the march from fee-for-service to value-based, whole-person care. Wide-ranging changes in federal rules and laws – ranging from no reimbursement for 30-day re-admissions to allowing hospital foundations to spend on housing – have motivated the shift by large healthcare systems and networks.
The University of Illinois Hospital, where Brown works, launched the Better Health Through Housing program in partnership with Chicago Center for Housing and Health. The program was launched in February 2019 after the success of a randomized controlled trial conducted in the early 2000s. The study demonstrated the efficacy of “housing first”, or placing a homeless person into a permanent residency program without preconditions. The program pays $1,000 a month for up to 12 months, and the program figures it cost another $1,000 a month for other expenses, or about $25,000 a year. With an ER visit costing about $1,200 and an overnight stay in a hospital costing upwards of $3,000, the economic reality clearly supports a housing solution to chronically ill and homeless patients.
In Denver, to cite another example, Denver Health is partnering with the Denver Housing Authority to develop a former shuttered 10-story office building for patient housing. Denver Health made the decision after it treated more than 100 long-term homeless patients in the first half of last year alone. All of the patients could have been treated at home, but they were homeless. Legally and morally the hospitals cannot discharge an inpatient if they don’t have a safe place to go.
“Those people are, for lack of a better term, stranded in our hospital,” said Dr. Sarah Stella, a Denver Health physician.
It’s Not Just the Poor Who Are Impacted by SDoH
A 2017 study by the National Academy of Medicine (NAM) confirmed that SDoH have a far-reaching impact on health, determining up to 80-90 percent of outcomes. Such whole-person care is surprisingly not just limited to the poor. A DIVE analysis found that 68 percent of patients suffer from at least one SDoH challenges, with 57 percent at moderate risk for financial insecurity, addiction, transportation access, food insecurity, and health literacy. A 2016 study in the Journal of the American Medical Association found that income was linked to health outcomes.
“Research…shows that at all levels of income, our health is affected by economic conditions, so even middle-class and upper-middle-class people are in worse health than richer people,” said APHA member Steven Woolf, MD, MPH, director of the Virginia Commonwealth University Center on Society and Health. “We’re all in this together — it’s not a problem restricted to the very poor.”
HMIS Data Strategies are Effective
Hospital and social services case managers are more and more recognizing the efficiencies of working together and sharing information through Homeless Management Information Systems (HMIS). Doing so reduces costs related to ER visits and extended inpatient stays and provides better outcomes. A robust data management solution is essential to identify people who would benefits from such innovative solutions such as medical housing.
SDoH 101 for Better Health Results
The NAM study summarized five urgent findings that should serve as motivation for any locality considering a HMIS data solution to improve SDoH and healthcare outcomes:
1. As a determinant of health, medical care is insufficient for ensuring better health outcomes: Data suggest that higher spending on social service in other first world countries is linked to lower healthcare costs and better outcomes.
2. SDoH are influenced by policies and programs, and associated with better health outcomes: Community partnerships that synergize medical interventions and PSE changes produce a more comprehensive approach to behavior change. For example, tobacco is a leading determinant of many health outcomes (e.g., mortality, quality of life), and decreasing tobacco use is more influenced by the price of cigarettes and smoke-free environments in the community than by the availability of cessation clinics or quit-lines.
3. New Payment Models Are Prompting Interest in the SDoH: New value-based payment models such as alternative payment models, accountable care models such as accountable care organizations (ACOs) and patient-centered medical homes, and Medicare Shared Savings are moving toward payment for outcomes rather than process measures, as well as benchmarks for “total cost of care.”
4. Frameworks for integrating SDoH are emerging: Data frameworks have been proposed for integrating SDoH into primary care and capturing SDoH domains in electronic health records (EHRs). One framework includes community-driven and individual data for use in primary care, recognizing that there are still questions about the effect on outcomes.
5. Experiments are occurring at the local and federal Level: As noted above, State innovation models are exploring connections among health care, social services, and some SDoH. ACOs are responding to nonmedical needs of patients such as transportation, housing, and food with the assumption that outcomes and cost will improve.