EXECUTIVE SUMMARY
The University of Illinois Hospital in Chicago has reduced healthcare costs by providing permanent housing for frequent ED utilizers with behavioral and medical issues who are homeless.
- Patients are identified by ED staff as homeless, having one or more chronic disease, and substance abuse issues.
- The Housing First model adapted by the hospital places patients in subsidized housing, then helps them with their problems.
- The hospital has partnered with the Chicago Center for Housing and Health, which provides case managers to help participants navigate the healthcare system and teach them basic life skills.
By providing permanent housing for homeless patients with medical and behavioral health issues who are frequent ED utilizers, a pilot program at the University of Illinois Hospital & Health and Sciences System (UI Health) in Chicago has reduced healthcare costs by 27% for the 27 patients in the program.
When the costs of care for four cancer patients is subtracted, the program has resulted in a 67% drop in healthcare costs, according to Stephen Brown, MSW, LCSW, PMP, director of preventive emergency medicine at the 495-bed tertiary care teaching hospital.
Patients in the program are frequent ED and psychiatric ward utilizers who are homeless and have a combination of chronic medical conditions, behavioral health issues, and substance abuse problems.
Homeless people tend to come to the ED because they don’t have a place to live, particularly during the winter months, Brown says. “They’re accessing the emergency department for secondary gain — it’s warm, they can get a sandwich, and they can sleep there,” he says.
The ED also functions as a safety net for many people with severe and persistent mental health issues who get kicked out of shelters because of behavioral problems, and come to the ED rather than sleeping outside, Brown says.
Before starting the program, the hospital analyzed the cost of care for 48 homeless patients and found that they were five times higher than the average patient’s costs, Brown says. The hospital identified more than 575 patients in its system by data mining and identifying patients who gave crisis shelters as an address. “Looking back, more than 1,300 homeless patients have accessed the hospital since 2008,” Brown says.
UI Health partnered with Chicago’s Center for Housing and Health to demonstrate the Housing First model of care to draw attention to the model locally and to create a healthcare-to-housing pilot, Brown says. Housing First is a national model that provides permanent housing and supportive services to homeless people.
“The chronically homeless have high rates of mental illness and substance abuse. In the past, by expecting them to follow their treatment plan even though they didn’t have a place to live, we set them up to fail,” Brown says.
The traditional model starts by getting the homeless help with substance abuse, then finding them housing if they are cooperative. But only 20% of people in the traditional program stay in the housing, he says.
“The Housing First philosophy and process doesn’t have preconditions. It’s based on the idea that without the stability of a basic human need, such as housing, people have extreme difficulty attending to their medical care,” he says. Those in the Housing First program have a 90% retention rate because they have permanent, supportive housing, he reports.
The cost of healthcare decreases significantly when the chronically homeless have a place to live and psychosocial support, Brown says. Nationally, the Housing First model results in a decrease in costs that ranges from 38% to 72%, he adds.
“People need basic necessities, like a place to live, before they can deal with their physical and mental health issues,” Brown says.
Participants in the program are identified through the ED staff and by a panel of providers who meet regularly and assess the medical conditions, frailty, and healthcare utilization of frequent ED visitors. The panel includes social workers, ED physicians, a psychiatrist, and, sometimes, an ethics specialist, Brown says.
Many of the patients are identified by the ED social workers, he adds. Criteria include chronic homelessness plus a disabling chronic disease, and substance abuse issues. The hospital uses the U.S. Department of Housing and Urban Development’s definition of chronic homelessness: homeless for more than a year, or episodes of homelessness over a three-year period.
Participants in the program tend to be a lot sicker than the average patients, Brown says. “We look for tri-morbidities: psychiatric, medical, and chronic conditions, along with substance abuse. We try to balance healthcare utilization and medical necessity,” he says.
The homeless population has a high rate of head and neck cancer due to smoking, which is common in the mentally ill population, and alcohol abuse, he says.
Many of the chronically homeless have suffered traumatic brain injuries or some form of neurocognitive impairment similar to dementia, he says.
For instance, one 35-year-old patient has been to the ED 85 times in the past year. “An assessment of his neurocognitive status shows that he is significantly impaired. He can’t function independently,” Brown says.
The patients in the program don’t socialize well and need to have a one-bedroom apartment so they can live independently, Brown says.
The hospital works with 28 different housing agencies that manage about 140 one-bedroom apartments scattered throughout the city of Chicago to identify suitable housing for participants. “It works better to place the participants in different places, rather than concentrating people with mental health and substance abuse issues in one building,” he says.
The Chicago Center for Housing and Health partners with the hospital and provides the case managers who work with patients in the program. The case managers have a caseload of 15 patients, enabling them to spend a lot of time with each individual, Brown says.
“The case managers come from the housing world and spend a lot of time troubleshooting, solving problems, and overcoming barriers to care. They are the glue that holds the program together by teaching participants basic life skills, like how to get a medical appointment and how to pay rent,” Brown says.
The healthcare costs for most of the patients in the program are covered by Medicaid as a result of the Affordable Care Act’s Medicaid expansion, Brown says. The hospital created a fund of $250,000 to provide housing for the participants.
So far, the program has obtained supportive housing for 27 patients. Three of them have died of cancer and one is receiving palliative care.
“Some of the emergency department physicians were skeptical when we started this program, but now they’re big supporters,” Brown says. As news about the pilot program’s success spreads, other hospitals in the area are showing interest in the Housing First model, he adds.
“If our society gave the chronically homeless a place to live, we could cut their medical costs by a third to a half. This is something that every hospital should be doing, anyway. We are discovering that it works and it is cost-effective. And it’s simply the right thing to do,” he says.
By providing permanent housing for homeless patients with medical and behavioral health issues who are frequent ED utilizers, a pilot program at the University of Illinois Hospital & Health and Sciences System in Chicago has reduced healthcare costs by 27% for the 27 patients in the program.
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