Chronically homeless patients account for most of Chicago-based University of Illinois Hospital (UI-Hospital) and Health Sciences System’s so-called “super users” of medical care. Health care costs consumed by super users are five to 15 times the average patient’s cost of care, says CEO Avijit Ghosh, M.D.
“These patients return again and again, with no improvement in their health,” he says.
He says chronically homeless patients come to the hospital not just because they are sick, but also to get a sandwich and a hot cup of coffee when they are hungry, and for a warm place to stay and sleep on cold nights.
“If you do not have housing, you do not have the kind of stability that allows you to achieve better health,” Ghosh says. “We thought we should do something about it.”
In late 2015, UI-Hospital launched its pilot “Better Health Through Housing” initiative. The health system committed $250,000 to provide furnished one-bed room apartments and support services for 27 homeless patients.
Ghosh says the hospital’s costs for paying for these super users of care was nearly $3,000 per day. Under the Better Health Through Housing initiative, the hospital contributes $1,000 per patient per month to Chicago’s Center for Housing & Health, which places the program’s patients into temporary units until permanent apartments can be arranged. The center has 125 apartments for permanent placement scattered throughout the city, so patients can choose the location that works best for them.
“We did not go into this to try to solve the homeless problem,” Ghosh says. “We are just trying to see how we can take better care of these patients.”
The results so far are promising. The number of monthly hospital visits for participants dropped by 35%, and the cost of caring for them, on an annualized basis, fell by more than 40%.
A panel of UI-Hospital physicians, social workers, nurses and other staff maintain a list of potential patients for the program. At the start of the project, the team had a list of 48 patients who had been identified as homeless. The list has grown to more than 500 names.
“The homeless are invisible in health care because no one documents them in a way that makes them easy to find,” says Stephen Brown, UI-Hospital’s director of preventive medicine and the housing program’s manager.
UI-Hospital’s efforts, of course, are a drop in the bucket in a city where 6,300 adults are estimated to be homeless at any given time. But Brown says housing for the homeless is just common sense, when you factor in the costs of attending to chronically homeless residents at places like hospitals, psychiatric facilities, food pantries, shelters and jail.
“We could reduce the societal costs by a third to a half if everyone had a place to live,” he says. “It begs the question, why should we allow anyone to be chronically homeless?”
UI-Hospital’s program is patterned on the “Housing First” policy endorsed by the Department of Housing and Urban Development in 2002. Under the Housing First model, residents are given regular leases, without their housing hinging on attending therapy or other conditions.
These partnerships successfully link stable housing to better health, says Peter Toepfer, the Center for Housing and Health’s associate vice president of housing. “They are a life-changing solution for very ill people who have experienced long-term homelessness,” he says.
And Toepfer says hospitals and health systems should view chronic homelessness much as they do a chronic illness. “The best prescription you can write for a homeless patient is permanent supportive housing,” he says.
Community health advocates say UI-Hospital’s efforts illustrate the critical role that hospitals and health systems can play in managing population health.
“As payers move to value-based models, hospitals like UI-Hospital that take on these social determinants are uniquely positioned to succeed in serving mission and improving their bottom line,” says Barbara Otto, CEO of Chicago-based Health and Disability Advocates, a non-profit social services organization.
UI-Hospital has extended its program through the end of the year, with the hope that it fosters a broader conversation in the city about housing as health care for the homeless. Ghosh wants to put together a broad collaboration of health care providers and insurers, community groups, public agencies and philanthropic organizations that can lead to comprehensive policies for ending homelessness in the city.
“It needs to be the next step,” he says. “There is only so much any hospital can do on its own.”
What also is needed are more finely attuned financial incentives and payment strategies to support hospitals’ and health systems’ investment in managing population health, Ghosh says.
“The payment system still does not incentivize you to do these types of things,” he says. “We have been talking about population health and we are slowly moving towards it, but we need more of a transformation in the payment system.”
The stories below look at what other hospitals and health systems are doing to address homelessness in their communities.