Alternatives to discharging people who are homeless to the street….

 Background

People experiencing homelessness are heavy users of the health system, frequently presenting to Emergency Departments with acute health issues that often result in lengthy hospital admissions. WA Health data shows that the average length of stay for patients with no fixed address is double that of general population – the lack of suitable accommodation post-discharge for homeless patients means that they face either longer inpatient admissions in expensive hospital beds or are discharged when too unwell for the challenges of living on the street, which results in deteriorating health and high numbers of unplanned hospital readmissions. People who are homeless also miss out on necessary elective procedures because they lack a safe hygenic supportive environment for pre-admission preparation. One innovative solution to this however are Medical Recovery Centres, based on the Respite Center model, which originated in the United States.

Dr Jim  O’Connell who established the first US Respite Center in Perth 5-11 Nov 2018…

The School of Population and Global Health (UWA) in conjunction with Homeless Healthcare and Royal Perth Hospital Homeless Team are very pleased to be hosting next week  James O’Connell from Boston Health Care for the Homeless Program (BHCHP). Dr O’Connell is here as a Raine/Forrest Medical Research Foundation 2018 Visiting Fellow.   Dr O’Connell has dedicated his career to research and practice in the field of homelessness, and is a global leader in the field. He is the founding physician of the BHCHP, serving over 13,000 homeless persons each year. With colleagues, Dr O’Connell established America’s first medical respite center for homeless persons in 1985; there are now over 70 of these across the U.S.A. and a growing number in Canada.

A key focus of Dr O’Connell’s visit will be to bolster support in WA for the urgent need for a Medical Recovery Centre in Perth. He will speak about the benefits of the medical respite model for people who are homeless in the U.S.A at a Homelessness and Health Forum on Nov 9 – this forum is being opened by Minister for Communities, Simone McGurk. Dr O’Connell will also participate in several meetings about this with government and non-government agencies while in Perth.

The Respite Center Model
A Respite Center provides stable pre and post hospital accommodation and support to people who are homeless but do not require hospital care. A Respite Center also enables patients to recuperate in a “home-like” environment where they can receive Hospital in the Home services as well as intensive social support input to link them with community-based support services, accommodation providers and long term GP services. Providing pre and post hospital care and support is common across all respite centers, but what they ‘looks like’ can vary – for example, some are co-located near to a hospital, others are close to homelessness services; length of stay and number of beds can vary.  Typically clients can receive in reach support from hospital services, which is still more cost effective than having them occupy a hospital bed.

The proposed Medical Recovery Centre (MRC) model for Perth 

The MRC model proposed for Perth by Homeless Healthcare and St Barts is unique in the combination of medical and social support that will be provided. A major driver of the poor health of homeless people is that they are not housed. Time spent in the MRC is a perfect opportunity to deal with this lack of housing that drives this poor health.

This is a cost effective solution for Government given the high rates of ED presentation and hospital re-admission when people remain homeless. Moreover published evaluations of US respite centers show reductions in ED presentations of between 24% and 36%, and reductions in inpatient days of  between 29%- 58%, equating to millions of dollars in reduced healthcare use.  St Vincent’s Hospital Sydney has a 12 bed offsite shorter stay respite unit for people who are homeless, where support and care following discharge is provided for around $400/day; far cheaper than a hospital bed day (average cost in Perth $2718/day)

Why does Perth need an MRC?   As we argued in a recently published paper in the MJA[1], at the core of the poor health of people who are homeless is the absence of safe and secure accommodation. This is particularly apparent upon discharge from hospital when people experiencing homelessness are discharged before they are well enough to return to the streets. Even when patients are discharged to crisis or temporary accommodation, these do not provide the rest, recuperation and follow up care needed.  For people who are homeless and rough sleeping there are enormous barriers to recovering after a hospital admission including lack of places to wash and rest, no secure storage for medications, poor nutrition and sleep and difficulty maintaining hygienic wound care. These challenges also prevent rough sleepers preparing for and accessing elective hospital procedures.  The case study in Box 1 gives a recent Perth example of a Homeless Healthcare patient who would have benefited from an MRC.

Box 1: Case Study Benefits of MRC

Background

Henry is a male in his mid-forties who has experienced homelessness for 20 years and has a multitude of serious chronic health conditions and trauma.  Henry’s health issues include hepatitis C, heart problems and drug use issues. Added to this are a brain injury and learning difficulties.

Presentations to Per RPH and WA hospitals

Between 2015 and 2017, Henry presented to the ED 48 times and had 18 inpatient admissions, equating to 89 days in hospital). Recorded reasons for hospital admissions were diverse, including back pain, hallucinations, auditory issues, suicidal ideation, benzodiazepine overdose, gastrointestinal issues, drug and alcohol intoxication, pelvic fracture, chest pains, pneumonia, hip pain, cellulitis and a psychiatric review. The resultant cost associated with his ED presentations and inpatient admissions was $326,093.

Why this patient would benefit from an MRC

Complex patients such as this are ‘bouncing balls’ in the hospital system with very short hospital stays which do not address the multitude of issues and result in further presentations. They also have catastrophic events, such as Henry’s motor vehicle accident in 2017, which lead to very prolonged admissions, as demonstrated above. When major injuries or illnesses strike a person who is homeless, the admissions are generally long and difficult, and early discharge results in further complications and admissions. An MRC can markedly reduce the LOS of these catastrophic events, comparable to a housed person because they have a place of rest, supervision and access to home hospital services. The MRC will also use this time for stabilisation of mental health and AOD problems which cannot be done on the streets, and therefore smooth the path to long-term housing.

In a meeting in September, the WA Premier, Health Minister and Housing Minister indicated strong support for a Medical Recovery Centre in Perth for pre and post hospital care for people who are homeless, but funding still needs to be committed to progress this.

Published international studies demonstrating reduction in hospital use for homeless people admitted to medical respite care

study Observed reduction in number of ED presentations  Observed reductions in number of hospital inpatient admissions MRC average length of stay
Sadowski (2009)[2]

 

Basu (2012)[3]

(cost analysis for Sadowski 2009)

 

24% decrease ED 29% decrease IP 14.4 days
Buchanan (2006)[4] 36% decrease in respite group, but did not reach statistical significance. 58% fewer inpatient days (3.4 vs 8.1 days; P = .002)

 

49% reduction in hospital admissions

 

Ave LOS in respite was 42 days
Kertesz (2009)[5]

 

 

50% reduction in odds of readmission at 90 days post-discharge

 

Mean LOS 6.4 days

 

[1] https://www.mja.com.au/system/files/issues/209_05/10.5694mja17.01264.pdf

[2] Sadowski LS , Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May;301(17):1771-8.

[3] Basu A, Kee R, Buchanan D, et al. Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care. Health Serv Res. 2012 Feb;47(1 Pt 2):523-43.

[4] Buchanan D, Doblin B, Sai T, et al. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006 Jul;96(7):1278-81.

[5] Kertesz SG, Posner MA, O’Connell JJ, et al. Post-hospital medical respite care and hospital readmission of homeless persons. J Prev Interv Community. 2009;37(2):129-42