Health Through Housing: North - PowerPoint Presentation

Health Through Housing: North Carolina Impacts Findings from Two Recent Research Studies 2019 North Carolina Affordable Housing Conference Donna J. Biederman, DrPH, MN, RN

Overview / ObjectivesStudy #1 – Homeless Medical Respite Pilot EvaluationDescribe homeless medical respiteDiscuss connection to benefits and changes in health care utilization pre- and post-respite Study #2 - Health, health care utilization patterns, and entry into homelessness of persons evicted from public housing Describe a novel method for finding persons evicted from public housing Discuss the health and health care utilization patterns of persons pre- and post-eviction

What is Medical Respite?“…acute and post-acute care for persons experiencing homelessness who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to be in a hospital .” National Health Care for the Homeless Council (2019) https ://nhchc.org/clinical-practice/medical-respite-care /

Medical Respite Programs in US (n=65)

Medical Respite – Benefits & ChallengesBenefitsDecreased hospital days (Sadowski, Kee, VanderWeele, & Buchanan, 2009; Buchanan, Doblin, Sai, & Garcia, 2006) Decreased Emergency Department visits (Sadowski, Kee, VanderWeele, & Buchanan, 2009) Decrease healthcare costs (Basu, Kee, Buchanan, & Sadowski, 2012) Improved housing outcomes (Meschede, 2010; Zerger, 2006) Challenges Participants leaving against medical advice (Bauer , Moughamian, Viloria, & Schneidermann, 2012)

What we knowHomeless people need a clean and safe place to recover from illness / injury (i.e., medical respite).Lack of a medical respite program has detrimental effects on both homeless persons and health care providers and results in health system inefficiency. Biederman , D. J., Gamble, J., Manson, M., & Taylor, D. (2014). Assessing the need for a medical respite: Perceptions of service providers and homeless persons. Journal of Community Health Nursing, 31(3), 145-156. doi : 10.1080/07370016.2014.926675 PMID: 25051320

Homeless Medical Respite Pilot Program EvaluationPreliminary Results – Year 1

Respite Referrals (n=44)

Patient Characteristics (n=29)Mean Age 47.3 ± 8.5Race Black – 52% (15)White – 45% (13)Multiracial – 3% (1) Ethnicity Hispanic – 3% (1) 90% Male (26)

Respite Payment Sources (n=29)

Housing Pre / Post Respite (n=29)

Benefits & services obtained through respite program (n=29)

ED Visits

Inpatient Admissions

Inpatient Days

Outpatient Visits

Utilization SummaryED utilization did not change37% reduction in Inpatient Admissions70% reduction in Inpatient Days 192% increase in Outpatient Visits

Charges and Payments (n=29) Charges Payments % 1 Yr Pre Respite $3,492,662 $247,236 7.1 During Respite $371,009 $39,319 10.6 1 Yr Post Respite $1,794,136 $144,037 8.0 Summary: 51% decrease in charges from 1 year prior to 1 year post intervention; slight increase in % of payments to charges Biederman DJ, Gamble J, Wilson S, Douglas C, & Feigel J. Health care utilization patterns and connection to services following a homeless medical respite pilot intervention. Public Health Nurs . 2019; 36(3):296-302.

Program Expansion with Hillman Innovations in Care Grant Biederman, DJ, Gamble JC, Wilson S, Duff LK, Bristow E, & Wiederhoeft, L. Transitional care for homeless persons: An opportunity for nursing leadership, innovation, and creativity. Creat Nurs . 2016; 2(22), 76-81.

Kate B. Reynolds Charitable Trust Award

Homeless person identified through DUHS, PADC, DHCT, LCHC, or Community Paramedic Program & referred to Transitions Consult Clinic Durham Transitions Consult Clinic Assessment tools to guide decision making: Calgary Singles Acuity Scale and Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) Expected outcomes: improved housing status, primary care connection, increased outpatient visits, decreased inpatient days, increased perceived health status. Potential for field visit by nurse practitioner to engage patients connected to Community Paramedic in primary care No acute medical or mental health needs. Self reliant. Refer to Housing Specialist 10 cases / year Ongoing medical need. Few supports. Not self-reliant. Refer to DHCT for medical respite and / or 9 month case management program. Housing Specialist involvement 20 cases / year Acute mental health issues and / or medical needs requiring higher level residential care (ALF, SNF). Consult case. Provide guidance regarding available community recourses to referring entity. 35 cases / year Limited ongoing medical need. No acute mental health needs. Self-reliant. Brief medical intervention by NP. Establish and / or assist to maintain connection to PCP. Referral to Housing Specialist and Duke Well. 30 cases / year NP assesses patient & determines best path Extreme acuity High acuity Medium acuity Low acuity

End Study #1

Health, health care utilization patterns, and entry into homelessness of persons evicted from public housing Donna J. Biederman & Ashanti Brown

BackgroundHousing instability affects healthSelf-reported fair or poor maternal and child health 1,2 Maternal depressive symptoms 1,2 Child lifetime hospitalizations 1 Persons living in public housing have worse health than persons in other housing situations 3 Housing instability can lead to eviction and homelessness Increased focus on eviction nationwide 1 Sandel et al. (2018). Unstable housing and caregiver and child health in renter families. Pediatrics, 141 (2), e20172199 2 Desmond & Kimbro (2015). Eviction’s fallout: Housing, hardship, and health. Social Forces, 94 (1), 295-324. 3 Ruel et al. (2010). Is public housing the cause of poor health or a safety net for the unhealthy poor? Journal of Urban Health: Bulletin of the New York Academy of Medicine, 87 (5), 827-838.

Research questionsIn the past 5 years (1/2013 – 12/2017), how many people were evicted from DHA public housing communities? What were the characteristics of persons who were evicted? What were the health (mental and physical) conditions of people who were evicted? What were the health service utilization patterns (i.e., ED, inpatient, and outpatient visits) of people who were evicted a year prior and post eviction ? How many evictions resulted in literal homelessness? What individual characteristics were associated with literal homelessness?

Methods

Identifying persons evicted using DHA financial records *Financial transaction associated with this event

Matching in other systems258 heads of households were evicted in the 5 year time periodIdentifiers were provided to DUHS and NCCEH to match in their respective systemsHad to be exact match on first name, last name, and DOB. Other identifiers such as address and phone number were available for matching as needed.

Results

Who was evicted? 258 heads of households, 39 additional adults, and 380 children for a total 677 individualsHeads of household (HoH ) characteristics: 97% non-Hispanic Black / African American 80% female 88% were in single adult households 7% were < 24 years old; 6% were > 60 years old 30% of households had no children, 48% had 1 – 2 children, 22% had 3 – 5 children

Who matched in DUHS EHR? 231 (90%) of HoHs were matched 224 (87%) had at least one encounter in the study time period 152 (59%) had at least one pre and post eviction encounter

Diagnostic categories Category # of dx names Examples Chronic – Top 7 465 Cancer, diabetes, heart dx, kidney dx, lung dx, stroke Chronic – Other 694 Pain , musculoskeletal, GI, GU, ENT, skin disorders Acute 1042 Injuries, illness, infections, pain, musculoskeletal, ENT Mental health 164 Anxiety, depression, PTSD, sleep disorders, major MH dx Substance use 109 All substance use including tobacco Infectious diseases 115 Hepatitis, HIV / AIDS, other STIs, TB Disabling conditions 28 Wheelchair bound, amputee, impaired hearing or vision Social diagnoses 28 Financial difficulties, DV, sexual assault, homeless Pregnancy Related 325 Both complications of and well pregnancy visits Preventive 260 Screening, immunizations, routine exams

Diagnoses of participants pre/ post eviction (n=152) ICD-10 Category Pre Post % change P-value Chronic - Big 7 45 64 42.22 0.020 Chronic – Other 62 83 33.87 0.048 Acute 80 104 30.00 0.015 Mental Health 30 50 66.67 0.020 Substance Use* 36 47 30.56 0.373 Infectious Diseases 29 33 13.79 0.840 Disabling Conditions 8 11 37.50 0.427 Social Diagnoses 5 12 140.00 0.137 Pregnancy Related 21 30 42.86 0.264 Preventive 61 98 60.66 <0.001 * Includes tobacco

Health care utilization pre- and post-eviction (n=152) Variable Pre-Eviction Post-Eviction Mean Difference* P-value* Total number of Inpatient Stays 115 271 0.92 0.009 Total bed days 557.8 516.3 -0.76 0.608 Total Outpatient Visits 3324 4205 2.13 0.528 Total number of ED visits 517 930 1.99 0.013 30-Day ED Readmission 182 363 0.90 0.130 60-Day ED Readmission 238 491 1.26 0.078 90-Day ED Readmission 280 561 1.38 0.068 *adjusted for the difference in surveillance years before and after eviction.

Which homeless services were used? By who? Service Type, n (%) Singles (n=12) Families (n=22) Emergency shelter 10 (83.3) 18 (81.1) Rapid re-housing 1 (8.3) 16 (72.7) Transitional housing 1 (8.3) 3 (13.6) Permanent supportive housing 2 (16.7) 1 (4.5) Services only 0 1 (4.5) Non-Hispanic Black / African American (100%), Single (94%), Female (74%), with Children (71%), vulnerable age categories (18%)

LimitationsMethod of locating persons evicted in DHA could have resulted in some people being missedReduced sample size due to study time periodDetermining homelessness post eviction HMIS data is from three of the 12 CoCs in NC (represents 81 of the 100 NC counties)

Robert Wood Johnson Foundation Interdisciplinary Research Leaders Program Increasing housing stability: Assessing two promising housing support models to inform local, state, and national policy and practice Silberberg, M., Biederman, D.J., & Carmody , E. (2019). Joining forces: The benefits and challenges of conducting regulatory research with a policy advocate. Housing Policy Debate,3 , 475-488. doi:10.1080/10511482.2018.1541923

Discussion / Questions