Trading Hospital Doors for Front Doors: Hospital “Super Use” by People Experiencing Homelessness
As emergency physicians, caring for patients experiencing homelessness is a routine part of our job. Very rarely does an ER shift go by when we do not encounter at least one patient who is experiencing homelessness, and more often than not we will see many on a single shift. Often, we know these patients by name and their medical histories by heart because they come to the emergency department so frequently.
Though “frequent utilizers” and “super users” are now common lingo in health care and policy circles, the critical overlap with homelessness is sometimes overlooked. We recently published new research that underscores why we cannot forget homelessness when thinking about “super users.”
The first study, conducted at a hospital in New Haven, Connecticut, found that seven percent of Medicaid patients with four to six emergency department visits per year were experiencing homelessness, and 42 percent of those with 18 or more visits per year were experiencing homelessness. Another study discovered the same phenomenon among Veterans Health Administration patients; as number of emergency department visits increased, the proportion of patients who were experiencing homelessness increased exponentially.
The hospital door is often a revolving one for people who are experiencing homelessness. This is true not just in terms of repeat emergency department visits, but also repeat hospitalizations, which are even more costly to the health care system. Our research in New Haven found that half of hospitalizations among patients who were experiencing homelessness resulted in a repeat hospitalization within 30 days of discharge, nearly triple the rate for other Medicaid patients.
What can we do for people stuck cycling repetitively between homelessness and the hospital? While the care coordination, case management, and patient navigation offered by traditional programs for “super users” are important, they alone are not enough for patients experiencing homelessness. Indeed, even in the VA health care system, which exemplifies access to care and care coordination, we still find frequent emergency department use among people who are experiencing homelessness.
The best way to stop the revolving hospital door may be to give people another type of door: a front door to their own permanent supportive housing unit. Research has shown that providing high-cost patients with supportive housing can improve their health, reduce their hospital use, and reduce health care costs. More research is needed to further investigate these effects, and to help us learn what types of supportive housing work best for what types of patients. In the meantime, the available evidence suggests that supportive housing should be considered a critical element of any effort to reduce frequent hospital use for patients who are homeless.
These issues should be of particular concern to states as the Affordable Care Act Medicaid expansion will likely bring thousands more patients who are homeless onto the Medicaid rolls. Medicaid can actually be used to pay for some of the services, such as targeted case management, provided in supportive housing. The Corporation for Supportive Housing has created helpful “crosswalks” showing what services provided in supportive housing may be eligible for Medicaid reimbursement. New York State Medicaid has taken reimbursement for supportive housing a step further by providing “Medicaid Redesign” funding for new supportive housing construction and rent subsidies. The New York initiative, and the case for supportive housing as a health intervention, is described in a recent New England Journal of Medicine article.
Donald Berwick, former head of the Centers for Medicare and Medicaid Services, famously proposed a “triple aim” for health care of better care, better health, and lower costs. The more we recognize homelessness as a health crisis and supportive housing as a health care intervention, the closer we will get to achieving this triple aim for Medicaid “super users” who are experiencing homelessness.
Dr. Kelly Doran is an emergency physician and health services researcher at the New York University School of Medicine and Bellevue Hospital Center. She studies homelessness and other social determinants of health as they relate to health care.
Dr. Roberta Capp practices emergency medicine at the University of Colorado Hospital. Her research interests include care coordination, access to primary care, and frequent emergency department utilization for underserved populations, particularly those with Medicaid insurance.