January 25, 2018

Houston uses Medicaid dollars to fight homelessness—and has reduced ED use by 82%

Daily Briefing

    A Houston program that uses Medicaid funding to provide housing for homeless patients with high ED use has helped keep some patients out of the hospital, Renuka Rayasam reports for Politico.

    How one community's partnerships are transforming housing and health care for the homeless

    The challenge

    Rayasam reports that while "it's no great secret" that providing housing to high-cost patients can yield major public health returns, implementing programs that address both housing and health care can be a policy nightmare. The different agencies involved often have different regulations, organizational practices, and financing—which can thwart collaboration, Rayasam reports.

    At the federal level, HHS and the Department of Housing and Urban Development (HUD) have different definitions of homelessness. What's more, they have different rules as to which agencies can receive funding and how it can be spent. For instance, federal Medicaid money goes to the state and can't be spent on room and board that isn't considered nursing home care, while housing vouchers are spread across local housing agencies and can't be spent on health care, Rayasam reports. 

    At the local level, Rayasam writes, hospitals "often can do little more than discharge homeless people onto the streets with a handful of prescriptions," while housing providers can be quick to turn out tenants who violate their leases.

    But Houston's former Mayor Annise Parker's office made homelessness a priority, and with the help of a Medicaid demonstration waiver, approved under former President Barack Obama's administration, they crafted a unique approach to bridge those challenges.

    How the Houston program works

    The Houston program, called Integrated Care for the Chronically Homeless, provides permanent housing to about 200 individuals who were chronically homeless and who have been to the ED at least three times over the past two years.

    The program is funded in part by a state Medicaid demonstration waiver that allows Houston's health department to redirect some of the state's Medicaid funding to housing services. The city's housing authorities also have redirected some HUD vouchers.

    Under the program, each patient is connected with a three-person care team, which includes a nurse, a community health workers, and a case manager. Team members regularly meet to help patients adjust to housing, schedule medical appointments, and fill prescriptions, and they also provide support before a major medical procedure, Rayasam reports.

    To help prevent eviction, the care team meets with the housing provider to address potential problems. In addition, the housing provider has loosened certain regulations—such as a zero-tolerance attitude toward fights—to keep clients from losing their homes.

    But getting the program started was no easy feat, Rayasam reports, as it required health care organizations to play a larger role in non-medical homelessness services.

    When asked to take on more housing-related tasks, Frances Isbell, CEO of Healthcare for the Homeless-Houston, said, "We agreed, at the very beginning, including the staff, 'Wait a second, that's not our (responsibility)—that's the housing folks. They're the ones that should be dealing with that."

    But, ultimately, Isbell saw the value in the program, and her organization took on the role of providing housing support services—in some cases even donning protective suits to clean a tenant's apartment, Rayasam reports.

    Early success stories

    According to Rayasam, ED usage has dropped by 82% among clients who have been in the program for two years. One client had been to the ED 122 times in the year before he came into the program, but after he gained housing, his ED use fell to an average of 12 visits per year over three years, according to Isbell. While his use remained high, Houston's health care system was still saving money, according to Rayasam.

    One client, Andrew Brown, went to the ED about four times a year for asthma attacks. Since gaining stable housing about four years ago, he has not visited the ED at all. He also has been diagnosed with diabetes and is on medication for impulse control.

    "If I had not got housed, I probably would have ended up way sicker," Brown said.

    Uncertainty over renewal

    How much longer the program will continue is uncertain, Rayasam reports. The program is funded by a four-year waiver, and funding will end when the waiver does.

    The program's extension—and the potential for it to be scaled statewide—will require demonstrating to state lawmakers when they convene in 2019 that the program is worth funding.

    Project leaders plan to spend the next year doing the final math on the program. According to Rayasam, the calculation might be complicated by the fact that hospitals don't always record patients' housing status.

    However, Isbell believes that the cost analysis will support continuing the program. The program costs about $8,500 per patient annually, while one ED visit can cost between $740 and $3,437, according to a 2013 study.

    If the program is adopted by the state, Rayasam reports that the strategy could serve as model for other states (Rayasam, Politico, 1/10).

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