ACMA Hospital Case Management Research Series

Transcription

1 ACMA Hospital Case Management Research Series Questions in Case Management Homeless & Undocumented Patients

2 Report Contents Introduction The Homeless Population Health Concerns Hospital Impact Proactive Measures A Program Profile The Undocumented Population Health Concerns Hospital Impact Proactive Measures Page 2

3 Introduction: Homeless & Undocumented Patients Purpose & Source: The following report combines research and data from numerous sources to provide an overview of the current challenges facing hospitals and health systems with regard to the treatment and care of homeless or undocumented patients. Sources include articles from health care literature as well as data from the 2009 and 2011 National Hospital Case Management Surveys and ACMA s publication Collaborative Case Management. Data Sources This report includes data from the 2009 and 2011 NHCMS. The survey samples included hospitals with greater than or equal to 100 staffed beds. The samples were directed at acute care facilities - Psychiatric, Rehab, and VA facilities were excluded from participation. Each survey collected data from more than 400 hospital Case Management departments around the country. These data are nationally representative with a 95% confidence level (C.I. +/- 5%). Page 3

4 The Homeless Population According to the US Department of Housing and Urban Development, there were 649,917 sheltered and unsheltered homeless persons nationwide as of January U.S. Dept. of Housing & Urban Development 2010 Annual Homeless Assessment Report to Congress 2. NYC Department of Homeless Services Daily Report California, New York, and Florida accounted for 40 percent of the total homeless population. 1 As of December 9, 2011 the number of homeless persons using the New York City shelter system was 39, Additionally, about 1.59 million people spent at least 1 night in an emergency shelter or transitional housing during the 12-month period between October 1, 2009 and September 30, Both numbers show an increase from the previous year. 1 Page 4

5 The Homeless Population Health Concerns Homeless patients are more likely than others to be hospitalized for conditions related to: Substance use Mental illness Alcohol use 3 Additionally, prevalence of tuberculosis in homeless persons is estimated to be 20 times that of the general population. 4 In the homeless population, the prevalence of TB and HIV co-infection has been estimated at 34%. 5 Homeless adults have an age-adjusted mortality rate more than 3 times that of the general population The Health of Homeless Adults in New York City 4. Brewer TF, et al. Caring for the Uninsured and Underinsured Strategies to Decrease Tuberculosis in US Homeless Populations: A Computer Simulation Model. JAMA. 2001;286(7): Haddad MB, et al. Tuberculosis and Homelessness in the United States, JAMA. 2005;293(22): Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331: Page 5

6 The Homeless Population Hospital Impact Homeless patients underutilize primary and preventive health care and have high rates of Emergency Department usage. 7 40% of homeless persons in one study used the ED between 1 and 2 times in a 12 month period. 8% used the ED 3 or more times. Average length of stay for homeless patients is longer than for those of the general populations For New York City homeless persons, average length of stay was 9 days compared to 7 for the non-homeless population Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR.Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5): Page 6

7 The Homeless Population Hospital Impact Hospital case management departments report patient homelessness presents a challenge to the discharge process. 8 52% of facilities surveyed in 2009 and 50% in Facilities in California (68%) and Florida (58%) were most likely to report homeless patients pose challenging discharge barriers. 8. National Hospital Case Management Survey Page 7

8 The Homeless Population Proactive Measures Studies show hospitals have used innovative means to address the needs of homeless patients with positive outcomes for both the patient and the facility. Focused attention by hospital case management has been associated with decreased ED usage, cost, and homelessness. 9 The use of hospital hotels (hoptels) as discharge locations has been shown to be effective at reducing the inpatient length of stay for homeless patients to the level of the general population. 10 The use of homeless-centered primary care clinics can have a positive impact on reducing unnecessary ED visits and improving chronic disease management in the homeless population. 11 Linking hospital care, case management, and housing assistance has also shown positive results in the decline in ED admissions and hospitalizations for homeless patients Okin, RL et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med Sep;18(5): McGuire J, Mares A. Hoptel equalizes length of stay for homeless and domiciled inpatients. Med Care 38(10): (2000). 11. O Toole, TP et al. Applying the Chronic Care Model to Homeless Veterans: Effect of a Population Approach to Primary Care on Utilization and Clinical Outcomes. Am J Public Health. 2010;100(12): Sadowski, LS. 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;301(17): Page 8

9 The Homeless Population A Program Profile Interim Care Program (ICP) in Sacramento, CA The ICP is managed by The Effort and Salvation Army to provide temporary respite and recovery for homeless patients who are healthy enough to be discharged from a hospital, but have no housing alternative, family or other means of support. Four community hospital systems: Kaiser Permanente, Mercy, Sutter Medical Center, and U. C. Davis Medical Center discharge eligible patients to the respite facility The facility provides: Daily services Three daily meals Housekeeping and laundry ADA standard bathrooms Case Management services Provide access to ongoing health care through community health clinics Provide access to needed social services support through communitybased services. Interim Care Program (ICP) Program Contact Information INTERIM CARE PROGRAM Address: 1820 J Street, Sacramento, CA (executive office) Contact: Amber Salazar Phone: (916) asalazar@theeffort.org Web: Page 9

10 The Homeless Population A Program Profile The ICP provides patients with a clean and safe environment for up to six weeks. Patients are housed in a special 18-bed unit at the Salvation Army's Center of Hope facility in downtown Sacramento. Patient referrals by the four hospital systems are taken on a first-come-first-served basis. To date, 500 homeless patients have been referred to the ICP by all regional hospital systems. Average length of stay for patients in the program is 24 days. Outcomes indicate the ICP model works effectively to prevent readmissions to the hospital and improve health and quality of life for patients. To date, of the 500 participants: 65% have successfully completed the program with no returns to an Emergency Department 100% have been enrolled in health insurance programs 80% have received substance abuse treatment and mental health counseling 77% have been discharged into a permanent housing program The ICP was featured in an article in ACMA s publication Collaborative Case Management (Spring 2007). To read the article, go to: Page 10

11 The Undocumented Population According to the Pew Hispanic Center, there were 11.2 million undocumented residents living in the United States as of March California and Texas have the largest unauthorized immigrant populations. 13 Undocumented immigrants make up about 3.7% of the national population and about 5.2% of the U.S. labor force. 13 Most of these undocumented residents have no health insurance and are prohibited from obtaining insurance under the 2010 Patient Protection and Affordable Care Act Unauthorized Immigrant Population: National and State Trends, The Hastings Center Page 11

12 The Undocumented Population Health Concerns While many undocumented immigrants enter the U.S. in better health than their legal counterparts, they ultimately suffer from the same health issues. 15 Common chronic illnesses for Mexican and Latino undocumented immigrants include hypertension and diabetes. 15 Infectious diseases such as tuberculosis are more common in foreign-born persons incidence rate in 2007 was 10 times that of native-born persons Rumbaut, RG, Ewing, WA. The Myth of Immigrant Criminality and the Paradox of Assimilation. Spring Yecai Liu, et al. Overseas Screening for Tuberculosis in U.S.-Bound Immigrants and Refugees. N Engl J Med 2009; 360: Page 12

13 The Undocumented Population Hospital Impact Undocumented immigrants utilize health services less often than their legal counterparts. 17 Undocumented adult immigrants, who make up about 3.7% of the population, account for only about 1.5% of U.S. medical costs. 18 In Los Angeles county, undocumented immigrants comprise 12% of the population, but account for only 6% of the county s medical expenditures. 18 Many immigrants forego seeking medical treatment until their condition is severe. ED expenditures for undocumented immigrant children has been found to be almost three times as high as for nativeborn children Ortega, AN, et al. Health Care Access, Use of Services, and Experiences Among Undocumented Mexicans and Other Latinos. Arch Intern Med. 2007;167(21): Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff (Millwood) 2006;25: Mohanty SA, Woolhandler S, Himmelstein DU, Pati S, Carrasquillo O, Bor DH. Health care expenditures of immigrants in the United States: a nationally representative analysis. Am J Public Health 2005;95: Page 13

14 The Undocumented Population Hospital Impact Safety net hospitals increasingly feel the impact of undocumented patients in the form of uncompensated ED admissions. The current national health care reform policies do not allow health care coverage for the majority of undocumented patients. Under federal law, hospitals participating in Medicare must accept and treat patients seeking emergency care. Funding to offset cost of care for undocumented immigrants has ended but the requirement of care has not. Hospital case management departments also report undocumented patients present a challenge to the discharge process. 8 35% of facilities surveyed in 2009 and 32% in Facilities in Texas (57%) and California (51%) were most likely to report homeless patients pose challenging discharge barriers. Page 14

15 The Undocumented Population Proactive Measures Federal support for undocumented patients is minimal, but some states have elected to provide coverage. 20 In California, in certain counties or for emergency situations, immigrants with either legal or undocumented status may be eligible for Restricted MediCal, which can cover kidney dialysis, screening and treatment for breast and cervical cancer. The Access for Infants and Mothers (AIM) program, which is funded by the SCHIP unborn child option, is available for pregnant women. In Illinois, the AllKids program covers all children in families with incomes up to 800% of the federal poverty level, including undocumented immigrants. In Massachusetts, undocumented immigrants are eligible for the Massachusetts Health Safety Net which covers care at hospitals, hospital clinics, and Federally Qualified Health Centers. The Children s Medical Security Plan (CMSP) covers all children regardless of immigration status or income. This plan only covers primary and preventive care not hospitalization costs. 20. Rosenthal, M. State Practices in Health Coverage for Immigrants: A Report for New Jersey Page 15