By Harris Meyer*
After an injury, hospitalization, or surgery, people experiencing homelessness need a safe place to recuperate, with supportive services and referrals to a range of medical, behavioral, housing, and other services. But in many places in the U.S., they have no alternative other than returning to the street or a homeless shelter. As a result, they often go back to the hospital emergency department or are readmitted to the hospital. This results in worse health outcomes and higher medical spending.
Yakima Neighborhood Health Services (YNHS), a federally qualified health center (FQHC) in Yakima, Washington, launched a medical respite care (MRC) program in 2010 after a focus group of patients experiencing homelessness told a board member that they needed a place to stay when they were sick. Before that, YNHS providers would give recuperating patients a bus pass to use all day or tell them to rest at the public library.
Program: Yakima Neighborhood Health Services (YNHS) – Neighborhood Connections Respite Care
Population: Homeless adults recovering from illnesses, injuries, hospitalizations, or medical or surgical procedures
Goal: Provide temporary shelter and supportive services to optimize recovery, reduce the need for subsequent emergency department and hospital visits, and connect clients with primary care, behavioral care, benefit programs, and stable housing to get them on the road to longer-term recovery.
Key Features: Nurse-led team providing a full continuum of temporary housing and recovery services, backed by YNHS’ primary care and behavioral health providers and funded by Medicaid managed care plans.
The program started with five beds and was overseen by a registered nurse, offering medical oversight and short-term housing shelter during recuperation, behavioral health services, and referrals to primary care and other services.
The MRC program has grown to 10 beds at two congregate living sites, plus additional beds at several motels in Yakima and nearby towns in central Washington. A nurse, a case manager, a behavioral health specialist, and housekeepers served 96 homeless clients last year, less than the average of about 150 clients in the years before the COVID-19 pandemic. The staff connects clients with primary care, behavioral health, and addiction treatment providers at YNHS’ 10 clinics.
Seventy percent of the clients are adults aged 26 to 64, 15 percent are under 25 or younger, and a growing percentage (15 percent) are 65 or older, according to YNHS CEO Rhonda Hauff. Nearly 80 percent are covered by Medicaid in Washington, a Medicaid-expansion state, 14 percent are dually eligible for Medicaid and Medicare, and the rest are uninsured. In 2019, before the pandemic, the average length of stay was 19 nights.
The Yakima program is one of 133 medical respite programs for homeless people in 35 states and the District of Columbia, developed by FQHCs, nonprofit agencies, hospitals, homeless shelters, and other organizations, according to Barbara DiPietro, senior policy director at the National Health Care for the Homeless Council. The earliest programs started in the 1980s, but the number has grown significantly in the past decade, since the Council published published standards for medical respite care programs in 2016.
Patients experiencing homelessness are referred to the MRC program by local hospitals and YNHS’ clinics when they are injured or too ill to be in shelters or on the street, after discharge from the hospital, or when they are scheduled for surgery, chemotherapy, or other types of medical care requiring a recuperation period. To be eligible for the program, clients must be able to perform the activities of daily living on their own.
Some people experiencing homelessness who come into the program have previously refused health care, behavioral health, shelter, and other services. MRC can serve as their entry into the full continuum of services.
“It’s often the most vulnerable time in their lives, when they’re feeling particularly fragile, and they need recovery time,” Hauff said. “Getting them to accept respite has been a great opportunity for us. As they start feeling better, they look to our staff to help them find stable housing, employment, clothes, and other benefits like disability. That’s the road to recovery.”
For instance, Bob Davis, a man in his 70s who had long lived on the streets, was brought by a police officer from the hospital to the YNHS homeless resources center on a cold day in March 2018. He was accepted into the medical respite program despite showing early signs of dementia, and received a broad needs assessment, said Annette Rodriguez, the YNHS director of housing and homeless services.
He initially was resistant to accepting help, but he gradually warmed to the staff. “Bob always said no, but after relationships were built, he would say yes,” Rodriguez said.
After four weeks of respite care, the MRC staff secured access for him in a nursing home for people with dementia, where he lived for three years before dying last year. The MRC staff continued to visit him. With prompting, he remembered them. “You’re the crazy people who wanted to take care of me,” Rodriguez recalled him saying. “He lived his last days with some dignity. It’s a reminder of why we do what we do.”
The intake process starts with discharge planners at hospitals, clinics, same-day surgery centers, and chemotherapy centers talking with MRC staff and discussing patients’ medical conditions and other needs. The MRC nurse makes sure that the patient’s condition and needs do not exceed the care capacity of the program, since it’s not a skilled nursing center.
“We want to say yes to everyone, but we don’t want to set them up for injury,” said Hauff, who worries about turning down clients, sending them back to the hospital, and potentially causing their discharge back to the streets. “Our nurse says it’s safe or not.”
The staff sets the clients up in one of the YNHS’ two five-bed congregate living facilities in Yakima supervised by a resident manager, or, if those facilities are full, one of several participating motels that accept the program’s vouchers and that have attentive managers. Clients receive three meals a day, and wellness checks by staff at least once every 24 hours.
They also receive transportation to YNHS’ clinics, where they get primary care, behavioral health, and substance abuse services. A significant number of clients are started on medications for opioid use disorder, generally suboxone. In addition, they receive help signing up for Medicaid, disability insurance, and other benefit programs.
Very few clients have to be discharged because of behavior, Rodriguez said.
Besides reducing hospital readmissions or emergency department visits, a major goal is to get clients into stable housing, though that’s elusive because of the small supply in Yakima. In 2019, 25 percent of YNHS’ medical respite clients exited the program into housing, according to data provided by Hauff.
“This year we had just a small percentage able to exit into permanent supportive housing or transitional housing,” Hauff said. “Many return to the streets or to a shelter. If we kept everyone until housing was available, we wouldn’t have enough capacity in respite to help people recuperate from their acute condition.”
With the growing number of older adults experiencing homelessness, the MRC staff increasingly must seek out nursing home placements for clients after their recuperation period, though Medicaid beds in nursing homes are in short supply.
In a few cases where the client was terminally ill, the staff chose to keep the person in the MRC facility until death, similar to hospice. “They probably should have been in a long-term care facility, but they didn’t want to go, and our staff wanted to support them,” Hauff said.
YNHS originally started the MRC program with grants from Yakima County and several foundations. When the Affordable Care Act’s Medicaid expansion was implemented in 2014, Hauff approached Medicaid managed care plans and asked them to cover the housing and care coordination services offered by the MRC program.
YNHS now receives reimbursement for its MRC services from three of the four Medicaid managed care organizations serving the Yakima area. The plans cover the services voluntarily through a special arrangement with the state Medicaid agency. One plan pays a per-diem rate with an annual cap per patient, while the other two plans pay a case rate with either an annual cap per patient or a two-year cap.
Hauff said the average cost of MRC services is $140 to $160 per day, not including the primary care and behavioral care provided at YNHS’ clinics. Adding those services brings the cost to $350 to $400 a day. The MRC staff wants clients to receive as much primary care and behavioral care as they need, because the alternative is hospital care, which is much more expensive.
“We believe the value is really obvious, from the perspective of avoiding readmissions, providing better care, and giving people the opportunity to recover,” said Leanne Berge, CEO of Community Health Plan of Washington, which covers nearly 300,000 Medicaid and Medicare enrollees and is governed by the state’s community health centers. “It’s such an obvious solution to what would otherwise be a significant gap.”
Partly due to advocacy by Hauff and another organization that provides MRC, the Edward Thomas House at Harborview Medical Center in Seattle, Washington State is currently considering making medical respite care for homeless people a standard Medicaid benefit. With the potential for Medicaid funding, a number of other communities in Washington are launching programs.
DiPietro said at least seven medical respite programs in five states currently are receiving payment from Medicaid managed care plans, and at least two other states — California and Utah — are moving to have their Medicaid programs cover it as a standard benefit.
Like any programs that serve homeless populations, neighborhood resistance to having medical respite shelter facilities for local homeless populations can pose a challenge to organizations seeking to launch these programs, DiPietro said. But YNHS didn’t face any NIMBY, or “not in my backyard,” issues in establishing its two five-bed MRC shelters, which look like standard residential buildings, according to Hauff.
DiPietro said it’s often easiest to start an MRC within an existing shelter for people experiencing homelessness, though that may not work for clients who don’t like homeless shelters. “If you are doing homeless services in a new space, engaging the surrounding community can be challenging. However, high-quality medical respite programs offer solutions to many of the primary complaints that community members raise, such as seeing vulnerable people with obvious health care needs,” she said.
Based on feedback from local hospitals, Hauff said clients who receive medical respite care are 50 percent less likely to return to the emergency department or the hospital than if they had not received those services.
Hospital staff at Yakima-area hospitals reported that the respite care services provided to YNHS clients produced a total saving of 53 inpatient days in 2019 and 29 inpatient days in 2021, according to Hauff.
A 2021 literature review published by the National Institute for Medicare Respite Care, analyzing 45 research articles about MRC programs for the homeless nationally, found that:
- Without MRC, homeless patients have longer hospitalizations, are more likely to spend their first night post-hospitalization on the streets or in shelters, and have sub-optimal outcomes.
- MRC admissions decreased time spent in the hospital, emergency department use, and re-admission rates, resulting in cost-savings for hospitals.
- Without MRC, procedures and care are delayed due to medical providers lacking discharge options.
Berge said her Medicaid managed care plan hasn’t been asked yet by the state to document cost savings from MRC programs, because the patient numbers are small and it’s hard to build a control group. As MRC programs expand in Washington State, she added, there will be greater opportunity to document results with data.
“But we rely on anecdotal reality,” she said. “The individuals served otherwise would have reoccurring conditions and higher medical costs. It’s pretty obvious on the face of it that this is the right thing to do from a cost and quality perspective.”
Building relationships with people experiencing homelessness is key.
MRC program clients must be treated with dignity and respect, and if program staff can gain their trust, they can lead the clients into a continuum of recovery services that they may previously have resisted.
It’s important to medically screen individuals who are homeless carefully before accepting them.
Hospital discharge planners often are desperate to find a discharge option for homeless patients. But MRC clinical staff must make sure it’s safe to take the patient based on the resources and skill levels of the MRC staff.
Establishing medical respite as a standard Medicaid benefit would help expand the model.
Advocates for homeless services need to educate state Medicaid agencies and Medicaid managed care plans about the potential cost savings of MRC programs. If they started paying for the non-medical services provided by MRCs, that would encourage more communities to launch programs to fill this gap.
Thank you to Rhonda Hauff, Annette Rodriguez, Barbara DiPietro, and Leanne Berge for helping to inform this blog post.
*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.
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