Evaluation of Healthcare
for the Homeless
Program Impact on
Emergency Room Visits
NJPCA Region II Conference
June 3, 2010
Stephane Howze, MPH
Vice President, Healthcare Division
Harlem United
Background
• ER utilization has increased sharply nationwide (31% increase
from 1995 to 2005).[1]
• Homeless individuals account for a high portion of ER use;
they are three times more likely than the general population to
use the emergency department and tend to visit the ER
repeatedly.[2]-[3]
• Roughly 26% of New York City (NYC) populations live at or
below 200% of the federal poverty line, with poverty rates
being much higher in East and Central Harlem.[4]
• Homeless individuals often have limited access to
healthcare/primary care, have poor health status, and high rates
of co-morbidities due to multiple barriers to quality healthcare
2
Harlem United’s Response
• Integrated care Model - offer medical care that is
truly integrated with other essential services in a
culturally competent, supportive, healthy healing
community that meets clients’ multiple needs
• A “one-stop-shop” approach - allows members to
benefit from a wide array of services in areas of
medical and dental care, Mental Health services,
expressive therapies, and case management.
3
Harlem United – Who We Are
The Blocks Project
Supportive Housing Programs
•Innovative prevention initiative
• Targets neighborhoods with high HIV
prevalence, not high-risk sub-groups
•HIV education, testing and connection to
care
•Additional social services via partners
Case Management, Primary Care Support,
Treatment Education, Mental Health
Services, Substance Use Counseling,
Advocacy, Structured Socialization
FROST’D @ Harlem United
HRA Housing (Scatter-Site)
Supportive
Housing
Programs
Women’s Housing (Scatter-Site)
HUD Housing (Scatter-Site)
♦Injection Drug User Care ♦Harm
Reduction ♦Syringe Exchange ♦Testing
and Linkage to Healthcare
Prevention
Services
Education and Training
♦HIV Education and Community
Awareness events ♦African Immigrants
Services ♦Black Men’s Initiative
Transitional Housing
(Scatter-Site)
Emergency Congregate Housing
(Foundation House North & South)
Permanent Congregate Housing
Building Bridges Mental Health
Program
Dental
Clinic
Federally
Qualified Health
Center & Related
Services
Medical Care, Adherence
Support, Nutrition
Counseling,
Substance Use
Counseling, Structured
Socialization, Pastoral
Care, Expanded Syringe
Access Program
Testing Services
Primary
Care
(Westside &
Eastside)
Vocational Education Program
Adult Day Health
Center West
Delivery of CDC-sponsored effective
behavioral interventions ♦Healthy
Relationships ♦Many Men, Many Voices
♦Youth Space
Adult Day Health
Center East
Healthcare for the
Homeless
COBRA Case
Management
Fully Bilingual (Spanish/English)
Case Management, Treatment
Education, Support Groups, Harm
Reduction Counseling, Auricular
Acupuncture, Primary Care Support
Healthcare & related
services for the homeless
in Central & East
Harlem
Assessment,
Intensive Case
Management,
Advocacy, Crisis
Intervention
♦Rapid HIV testing ♦Innovative
recruitment strategies ♦Evaluation of
testing strategies ♦Connection to primary
care services ♦Access to HIV care through
ADAP enrollment ♦ Uptown Health Link
Evening Food &
Nutrition
Nutritional Assessment
and Support, Treatment
Education,
Psycho-Social Support
Mental Health
Services
Crisis Intervention,
Individual and Group
Psychotherapy,
Medication
Management,
Expressive Therapies
4
Harlem United - What We Do
• Founded at height of first phase of AIDS epidemic: 1988.
• In the early development, Harlem United (HU) specifically
served people living with HIV/AIDS (PLWH/As) who were
homeless and/or suffering from mental illness and/or
substance use.
• Agency of last resort for medically-underserved
communities of color in Harlem.
• Part of community-based movement to care for PLWH/As:
Founded to address lack of response from established
providers;
Responding to the unique personal, social, and institutional
barriers to care in Harlem.
5
Harlem United – Healthcare Division
ADHC
Article 28
License
1997
Primary
Care
Amendment
to
Article 28
License
2000
Dental
Amendment
to
Article 28
License
2003
El Faro
Extension
Clinic Open
ADHC & PC
2006
FQHC
Designation
Homeless
2007
Psychological
Services
Amendment to
Article 28
License
2009
CENTER OF
EXCELLENCE
MANAGING
CHRONIC
ILLNESS
2012
ALL VULNERABLE
HIV FOCUSED
PATIENTS
WITH A
ALL
VULNERABLE
MULTIPLICITY OF
PATIENTS
WITH A
NEEDS
MULTIPLICITY OF NEEDS
6
Harlem United – Healthcare & Related Services
Federally Qualified Healthcare Center
Healthcare services for the Homeless in
Central and East Harlem
Adult Day Health Center East
Adult Day Health Center West
Medical Care, Adherence
Support, Nutrition Counseling,
Substance Use Counseling,
Structured Socialization,
Pastoral Care
Community Case
Management
Assessment, Intensive Case
Management, Advocacy,
Crisis Intervention; VidaCare
Case Management;
Maintenance in Care
Primary
Care
Dental
Clinic
Healthcare
& Related
Services
Evening Food & Nutrition
Nutritional Assessment and
Support, Treatment Skillsbased Education,
Psycho-Social Support and
Harm Reduction
Fully Bilingual (Spanish/English)
Case Management, Treatment
Education, Support Groups,
Harm Reduction Counseling,
Auricular Acupuncture, Primary
Care Support
Wellness Center
Mental Health and
Substance Use Services
Crisis Intervention, Individual
and Group Psychotherapy,
Medication Management,
Expressive Therapies
7
FQHC – Healthcare for the Homeless (HCH)
• The FQHC-H designation allowed us to expand
services to homeless people in Central and East
Harlem communities who are predominantly African
American and Latino(a) adults, and have histories of
substance use and/or mental illness.
• This shift is very much aligned with our original
mission; both our traditional clients and our new
homeless clients are primarily poor, Africa American
and Latino(a) adults, have histories of substance use
and/or mental illness. All have experienced problems
accessing medical care and supportive services.
8
HCH Services – An Integrated Care Model
Dental Clinic
- Diagnostic X-rays and Exams
- Preventive Care
- Emergency Care
- Restorations
-Endodontics
-Prosthodontics
-Periodontics
- Oral Surgery
- Referral to outside specialists
for complex Surgical Procedures
Mental Health and
Substance Use Services
Crisis Intervention, Individual And
Group Psychotherapy, Medication
Management, Expressive
Therapies
Primary Care clinic
(Westside & Eastside)
Federally
Qualified
Health Center
GYN, Health Education,
Directly Observed Therapy,
Psychiatry services,
Preventive Health
Services, Management Of
Chronic Conditions
Other services
Referrals, Outreach, and Case
Management.
9
HCH Goals
• To increase access and eliminate barriers to care for
homeless individuals in Central and East Harlem
neighborhoods
• To improve health outcomes of homeless individuals
• To triage homeless individuals in Central and East
Harlem neighborhoods from Emergency Room to our
FQHC through HCH program
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Evaluating HCH Efficacy
 An outcome study was conducted in 2009 to evaluate
HCH efficacy
 Study Question: Are there differences in frequency
of ER visits among homeless clients who have been
receiving HCH services and those who are new to
HCH?
11
Method
Study Design: Cross-sectional study
Outcome variable: Frequency of ER visits
Sample
- Baseline group: new HCH clients who had their first intake
between January 1 – December 31, 2009
- Follow up group: clients who have been receiving services
provided by HCH, indicated by having at least two HCH visits
between January 1 – December 31, 2009.
Analysis
T-test to determine whether or not there are any differences in
frequency of ER visits among clients in baseline and follow-up
groups
12
Results – Demographics distribution
Both groups have similar
demographics distribution
% of clients
Age distribution
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
45% 48%
38%
29%
Baseline
Follow-up
14%
9%
8%
6%
0% 0%
<26
26-39
40-54
Age group
55-69
>70
13
HCH: –Diagnostic
Results
Diagnosis Distribution
distribution
Both groups have similar chronic illness distribution
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Results – Frequency of ER visits
Despite the similar demographics and chronic illness distributions, we observed a
significant difference in the number of ER visits among the baseline and follow up
groups.
Average number of ER visits
per person
Frequency of ER Visits in baseline and follow up groups
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Baseline
Follow up
Groups
15
Results – Frequency of ER visits
The difference in frequency of ER Visits among the baseline and follow-up groups could be
attributed to comprehensive HCH interventions, as evident in the following findings:
Percentage of clients
Distribution of services received among clients in the follow up group
120%
100%
• 33% are also engaged
in Dental
80%
60%
40%
•100% of clients in the
follow up group are
engaged in Primary Care
(PC)
100%
20%
33%
30%
Dental
Other services
0%
PC
•30% are engaged in
other types of services,
such as COBRA Case
Management, ADHC,
Maintenance in Care,
and Mental Health
Types of services
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Results – Frequency of ER visits
• Clients in the follow-up group have an average of three
follow-up visits in 2009. The visit types range from:
- PC follow-up
- psychiatric visits
- walk-in to get sick care
- psychotherapy visits
- etc
• Many of those visits would have been made to the
Emergency Room had they not been engaged in HCH.
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Conclusions
• Despite the absence of longitudinal analysis, findings
may be regarded as preliminary evidence of HCH
efficacy in triaging homeless patients from ER to HCH
• The convenience of our integrated care model, the
culturally appropriate safe atmosphere that we create and
the way we treat clients with dignity and respect are what
made the homeless population, despite their transient
nature, come back to seek care and comfort in our clinic
instead of utilizing the expensive Emergency Room.
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Evaluation of Healthcare for the Homeless Program Impact on ER