Bed and board for $25 proves a deal in LA
Arrangement keeps TB out of the shelters
No one disputes that homelessness is part of the tuberculosis picture in Washington, DC. How big a part it is and what to do about it has been a source of long-standing tension that has pitted public and private sectors in a dispute against advocates for the homeless in the city.
Recently, homeless advocates issued an ultimatum: Area shelters will no longer accept TB patients discharged from local hospitals. But with the TB unit at District of Columbia General closed and the District of Columbia Bureau of TB control chronically short-staffed, that left nowhere for such patients to go, and no outreach workers to ride herd on them.
Two percent of residents in the nation’s capital (population 540,000) are homeless, with estimates putting the number of homeless at somewhere between 5,000 and 15,000 people. The rate of TB cases among the homeless has doubled in the past year: from 6% in 1995, to 12% in 1996, with case totals increasing from 6 to 17. Worse, rates of HIV positivity among the homeless are high, accounting for about 33% of TB cases, says Wyndham Reed, technical advisor from the Centers for Disease Control and Prevention to the Bureau.
Neither the shelters nor a privately run non-profit network of clinics called Healthcare for the Homeless is equipped to deal with the problem. "The shelters are overwhelmed," says Margaret Kirby, RN, MA, coordinator at Healthcare for the Homeless’s HIV Day Center. "If you put people at shelters on directly observed therapy, they’re going to get lost, not take their meds, and then spread TB," Kirby says. The spread of TB among the portion of the homeless who are HIV-infected "is one of our big nightmares," she adds.
Luckily, the Bureau has just been awarded a $100,000 grant to provide beds for homeless TB patients, says Reed, who figures the money will enable him to get 20 people a year through an uncomplicated six-month course of treatment. A law on the books to prevent hospitals from discharging homeless patients without an OK from the public health department also would help a lot, Reed says.
In California, such a bill has recently been passed, says Paul Davidson, MD, MPH, the county’s TB control officer. There, the law is supplemented by something even more important: a safety-net arrangement that provides bed and board to homeless TB patients, once TB control approves their discharge. The bed-and-board arrangement has worked very well and has proven extremely cost-effective, says Davidson.
The program treats more than 90% of homeless TB patients through therapy and costs just $25 a day, compared with the $800 to $900 a day cost of hospitalizing someone. The TB control program convinced the county (which has money troubles of its own) to fund the program by showing it off in a demonstration project paid for with state money, Davidson says.
"New York City took sort of the opposite approach with Rikers Island," says Davidson, referring to the big city-run facility where New York detains many of its TB patients until they complete their treatment. "We decided our way was less costly and less destructive to the people involved," Davidson says.
The LA program uses a voucher system that’s pegged to medication. A client on twice-weekly therapy shows up Monday, typically, to get his medications, and, in return, gets three days’ worth of room and board vouchers. Thursday, he gets the remaining four days’ worth of vouchers.
Keeping tabs on vouchers is important
A key part of the program’s success is monitoring to make sure that the county isn’t paying for services that aren’t being used, says Davidson. "You have to track every night, every meal," he says, a task that keeps one staff member busy. "Occasionally, someone doesn’t show up; in theory, that means they shouldn’t get their vouchers," says Davidson. "But in reality, we’re pretty forgiving since our bottom line is to treat the TB."
The inexpensive hotels that provide the rooms for the majority of patients are delighted with the steady business, Davidson says, and patients are invariably grateful for a safe place to sleep. Providing a meal for $3 often translates as fast food, and that can be more difficult to find outside the downtown area, says Davidson. Downtown, a cafeteria that works with the homeless program is willing to provide meals for $3.
"It’s a system that’s worked very well here and which can be adapted to different localities," says Davidson. "I think it could be very cost-effective in DC, too."
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