How can we make Health Homes work for the Homeless?
Lessons from NYC HHC’s Chronic Illness Demonstration Project
Maria Raven, MD, MPH, MSc
Supportive Housing Network of New York
Sept 23, 2011
Hospital to Home (H2H)
• SDOH-sponsored Chronic Illness Demonstration Project
– HHC holds one of six State Department of Health
contracts
• Intensive care management and coordination for fee-forservice Medicaid patients at high risk for frequent
hospitalization
• Care Management Teams based at three HHC Hospitals:
• Bellevue, Woodhull, Elmhurst
• Enrolling patients since August of 2009
– 368 currently enrolled (540 cumulative)
– 51% enrollees homeless or precariously housed
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Hospital to Home’s task
• Find and enroll SDOH identified high-risk,
high-cost patients
• Intervene with the goal of reducing Medicaid
expenditures (read: hospital admissions)
• Improve health and social outcomes
• All for $291.50 per patient, per month
• “Supportive housing without the housing”*
*John Billings
How we do what we do
• Outreach, find, enroll
• Conduct in-depth assessment
• Develop care plan with patient using
motivational interviewing techniques
• Staff begin to work with patient, first on
immediate, then long-term goals
– Social Workers supervise Community Based Care
Managers (1:25 patient ratio), full-time housing
coordinator, some dedicated primary care
Homelessness and H2H
• We knew from pilot work that significant
numbers of eligible patients would be
homeless
• Partnerships with homeless services providers
a priority
• SDOH/NYSHF monies used to fund fulltime
Housing Coordinator
• No ability to have H2H enrollees prioritized for
housing
Most H2H patients are homeless or
unstably housed
• 37 % Housed
– 2/3 rent/own, 1/3 in supportive housing
• 22% Homeless
• 29% Non-permanent situation
– Institutionalized
– Staying temporarily with friends/family or in transitional housing
• 12% did not report
• Of 99 Housing Coordinator referrals:
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16 housed
20 stabilization bed/safe haven
41 shelter/drop-in center
52 HRA 2010Es submitted
Health system-housing partnerships are
key to this work
• We need you and you need us. Patients need us both.
• Health system is entry (and underused intervention
point) for homeless
– Many have spent more time with us that you know!
• Partnerships improve communication, reduce care
fragmentation, improve outcomes
• Poor planning and communication leads to PREVENTABLE
re-admissions, higher health care costs, poor outcomes
including death for most vulnerable.
• Un-housed patients delay getting care they need
H2H Partnerships
• Traditionally, health care folk have not intersected
with housing folk: increasingly this is a necessity
• All parties came readily to the table
– DHS, CUCS, Project Renewal, Common Ground, BRC
among others
• Targeted interventions tailorable to the individual
patient, incorporate patient input
• For the homeless, housing generally top priority
H2H Case Study: Ms. W
• Patient Overview:
• Post-Enrollment Activity:
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44 year old PR female, enrolled 9/09
Morbid obesity, IDDM w/
complications, HCV, HTN, CHF, renal
insufficiency, asthma, tobacco, prior
IVDU, depression, suicide attempts
Homeless in shelter at enrollment –
moved into supportive housing
12/8/09
Frequent hospital admissions for high
blood sugars and related infections
Difficulty remembering to take all of
her medications, depression
impacted motivation for tx and
attending appointments
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Mobile phone, appointment
reminders, transportation assistance,
moral support.
Connected to H2H PMD, subspecialists
Mental health, substance abuse
treatment & Smoking Cessation
H2H Housing Coordinator assisted
with housing placement
SSI appeal and PA workforce decision
Home care referral and services
advocacy
Monthly H2H support groups,
Recovery Clinic and at her residence
Encouraged self care – not putting
others’ needs first
Active listening – validating her
feelings and experiences
Comparing 12 months pre-enrollment to 12 months post:
3 hospitalizations vs. 1, over 60K in Medicaid savings
Hospital to Home’s immediate future
• Originally, a demo slated to end in March
2012.
– Evaluation would guide program’s future (or lack
thereof)
• Now: anticipated Health Home conversion
November 2011
• Eligibility criteria broadened, will no doubt
include even greater numbers of homeless
and precariously housed
Translating H2H into HH for the homeless
• Mobile phone technology
• Aggressive contribution to and tracking of
housing applications
• Formal partnerships with housing organizations
to enable:
– Bi-directional data sharing with patient
consent/assent
– Patient tracking before and after housing placement
– Patient co-management (what can we take off your
plate that makes sense?)
– Group meetings for difficult cases
What we need to (really) move ahead
• More flexibility around housing qualifications and eligibility
• Advocacy pre and post housing application submission:
maximize chance for success
• More permanent housing stock with liberal criteria around
chronicity and co-morbidities
• Private sector anyone?
• Formal connections and communication between the
health and housing delivery systems
– For both homeless AND those already in supportive housing
units
– On-site services investments for some
• Better health care system integration
What do these patients cost…and are
we making a dent?
• 263 H2H patients
• Minimum of 6 months pre-enrollment data
and 6 months post-enrollment data
• Average pre-enrollment cost to Medicaid, all
claims
– $5,928.85
– PER MONTH
– $71,146 per patient per year
Are we making a dent?
• Average post-enrollment costs to Medicaid
– $4,755.36 per person per month
– $57,064.32 per person annually
• Annual per-person Medicaid savings if numbers hold:
– $14,081.68 (20%)
– Over $3.7 million total for 263 patients (includes program costs)
• If costs decreasing, likely that hospitalizations and ED are
decreasing
• Matters as risk shifts from Medicaid (under FFS) to MCOs
• Matters because it’s likely a proxy for improved health
Homeless H2H patients
• Patient defined as homeless if referred to H2H
housing coordinator
– Only those currently homeless on street or in shelter
• 53 patients with at least 6 months of before and
after data
• $4,281.99 per month pre-enrollment
• $3,426.43 per month post-enrollment
• $855.56 per month in per-person Medicaid
savings (20% savings)
Where do the savings come from?
• Reduction in inpatient visits
– 0.68 per month to 0.36 per month
– 47% decrease (a 27% decrease in inpatient costs)
• Reduction in ED visits (T&R)
– 1.13 month to 0.53 per month
– 53% decrease (a 30% decrease in ED costs)
How could we use the savings?
Many Thanks
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Supportive Housing Network of New York
Bellevue, Elmhurst and Woodhull Teams
The New York State Department of Health
John Billings, NYU
Common Ground Community
NYC Department of Homeless Services
New York State Health Foundation
United Hospital Fund
New York Community Trust
HHC Central Office leadership
Krista Olson and Yuriy Libster
Predictive modeling to identify patients: Most
frequent users one year do not remain frequent
users the next
Examine utilization
for prior 3+ years
(Reference)
Admission
Predict admission
next 12 months
Risk score 0-100
Year 1
Year 2
Year 3
Year 4
Year 5
Health Care?
• Linkages to medical care
• Accompany individual to appointments
• Collaborate on discharge planning with inpatient teams
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Cell phone provision, support
Transportation assistance
Entitlements enrollment
Facilitate housing
Home visits/safety assessments
Reminder calls, alarm clocks, pill boxes
Support groups
24- hour call line with our staff on other end
“Patient Necessities Fund”