Medicaid programs begin to embrace respite care for the homeless


Various groups, clinics and organizations have set up places for people without housing to recover from injury, surgery and serious illnesses.

eEarlier this year, a homeless woman in her forties who had been living in her car went to the emergency department of a hospital in Orange County, California. It was found that she had ovarian cancer in the second stage. Since she did not have a home to return to upon discharge, the hospital referred her to the Illumination Foundation, a not-for-profit housing organization.

Foundation staff assessed the woman’s needs and admitted her to the 150-bed Recovery Care Center for the Homeless in Fullerton, Orange County. Medicaid women’s health plan covered the cost. Staff connected her with her primary care physician and oncologist to arrange chemotherapy. She is now receiving treatment and her condition is stable. She will remain in recovering care while the staff works to find her permanent home, according to Pooja Bhalla, DNP, the foundation’s co-CEO.

On any given night in the United States, it is estimated that 580,000 people are homeless. If they are injured or recover from surgery or a serious illness, they have no safe place to recover. As a temporary measure, hospitals and clinics sometimes give recovering patients a public transportation pass to use throughout the day or ask them to rest in a public library. Patients without housing often return to the hospital’s emergency department or are readmitted to the hospital. Health outcomes are worse than for patients who have housing and higher medical expenses.

In response, community health centers, homeless shelters, hospitals, and other organizations have launched 133 medical-relief programs, like the one used by women in Orange County, for homeless people in 35 states and the District of Columbia, and more are starting to work, according to Barbara DePietro, Ph.D., director of policy. Senior National Health Care for the Homeless Council.

There is no one way to run a rest program. Some programs, especially those of hospitals and clinics, are staffed by licensed medical professionals. Others use unlicensed personnel and bring in doctors, nurses, and therapists to provide care. Many only accept patients who can perform activities of daily living on their own and do not have a serious mental illness.

“We think the value is really clear, in terms of avoiding readmission, providing better care and giving people a chance to recover,” says Leanne Berg, CEO of Community Health Plan of Washington in Seattle, the nonprofit insurance company that operates Medicaid managed care and Medicare plans. Advantage.

Obstacles

But there are too few of these programs to serve all the homeless across the country who need housing and support during their recovery. Experts say there are a number of factors limiting its growth. It’s a cumbersome process for Medicaid plans to win state approval to cover these services, and many plans still don’t pay for it. Starting a medical respite program requires collaboration from a variety of community stakeholders, including neighborhood residents, and this can be challenging. In addition, there is no robust national data yet showing that these programs lead to overall cost savings and improved outcomes. However, a 2021 literature review published by the National Institute for Interim Medical Care found that without respite care, homeless patients have longer hospitalizations and suboptimal outcomes, and that respite care has resulted in cost savings for hospitals.

“It’s complex, it takes time and requires extensive thinking about how to work with partners,” says Karen Dale, CEO of AmeriHealth Caritas in Columbia, whose plan helped launch a medical respite program called Hope Has a Home in Washington, D.C., in 2019. . Another snag, she says, is that Medicaid plans “worry that if they invest and do all this work and one person is no longer a member, someone else benefits.”

Moreover, 12 states have not yet expanded Medicaid under the Affordable Care Act, which makes it more difficult for homeless relief programs in those states to fund their services because Medicaid is the primary source of coverage for people without housing.

Because Tennessee has not expanded Medicaid, “people in our non-sheltered community use the emergency room as their primary care provider, which raises costs,” says Julia Sutherland, executive director of The Village at Glencliff, a medical relief program for the homeless near Nashville. “This means that we spend hours sitting with our people in the emergency room when we can help them find housing, benefits and a job or take them to the eye doctor.”

Its program, which lacks Medicaid reimbursement, relies on support from the sponsoring church and contracts with local hospitals to serve their discharged patients in 12 single homes in the church’s former car park. But the lack of coverage makes it very difficult to engage participants in drug treatment. “It’s hard to tell someone who wants help that they’re going to have to wait,” Sutherland said.

road lighting

Illumination began its medical relief program for the homeless 12 years ago when leaders of local hospitals in Orange County realized they needed a safe place to get people out without housing, Bhalla explains. They asked Lighting to start a program.

The foundation has built a 150-bed facility in Fullerton with an affiliated medical practice on the top floor staffed by physicians, including psychiatrists and nurses. It has also established a free-standing 50-bed facility in Riverside County and supports curative care in motels in Los Angeles County.

A number of Medicaid plans, catalysed through the California Advancing and Innovating Medi-Cal Program, have agreed to offset baseline housing, case management, behavioral health, and substance abuse treatment it provides. They see evidence that the program improves outcomes for registrants and reduces costs.

For example, annual visits to the emergency department by homeless people enrolled in a CalOptima health plan decreased by 22% and inpatient admissions decreased by 26% one year after completing services at Illumination, according to a study conducted by Illumination in partnership with CalOptima. Total costs per member per month decreased by 23%.

While some Medicaid plans like CalOptima immediately approve enrollees for coverage in the foundation’s convenience program, others are skittish about approvals, particularly in Los Angeles County, Bhalla says. “Our family is empty because these plans don’t refer patients,” she said. “So hospitals have patients showing up in the emergency room who don’t need to be admitted.”

At least seven medical-relief programs in five states currently receive payments from Medicaid plans, and at least three states — California, Utah and Washington — are moving to have their Medicaid programs cover it as a standard feature, DiPietro says.

Medicaid reimbursement

Medicaid plans pay for rest programs in different ways. Yakima Health Services, a federally qualified health center in Washington that launched a temporary program in 2010, receives a daily rate with an annual per-patient cap on one plan, CEO Rhonda Huff says. She adds that two other plans pay the case price with either an annual cap or a two-year cap per patient, she said.

The average cost for rest services in five-bed facilities in the Yakima program is $140 to $160 per day, not including primary care and behavioral care provided in clinics. Add those and the total is $350 to $400 a day. Three of the four Medicaid plans serving the Yakima area of ​​central Washington voluntarily agreed to cover services. “The state is paying[Medicaid plans]to move people out of hospitals,” Berg notes. “It makes a lot of sense to develop these alternative settings.”

Hof found that medical respite can serve as an entry point for homeless people who previously denied medical and behavioral care, shelter, and other services. “It’s often the most vulnerable time in their lives, when they feel especially vulnerable,” she says. “When they start feeling better, they look to our employees to help them find stable housing, employment, clothing and benefits such as disability. This is the path to recovery.” However, the main problem with her program and others is that permanent accommodation is not available and many clients are returning to the streets or to a shelter. “If we keep everyone until housing is available, we won’t have enough capacity right away to help people recover from their acute condition,” says Hof.

DC . program

AmeriHealth Caritas DC embraced the medical convenience approach after Medicaid in Washington, DC, in 2016 switched to pay-for-performance contracts that penalized excessive hospital readmission plans and emergency department visits. But Dale says the main driver of the effort is a desire to improve health care and reduce disparities among the capital’s poor

Since its opening, Hope Has a Home has served 161 male patients referred by local hospitals in its eight-bed facilities, Dale says, including enrollees from all three Medicaid plans in the capital. Investing through reductions in preventable hospital admissions, 30-day all-cause readmissions and low-risk emergency department visits. Dale says her goal now is to open additional facilities for women, including pregnant women.

“Medical comfort is a great solution to addressing the social determinants of health,” she comments. “It should be explored by more insurance companies to build the health care delivery system in many places.”

Harris Meyer is a freelance journalist in Chicago who covers health care.


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