Evaluation of Healthcare for the Homeless Program Impact on Emergency Room Visits NJPCA Region II Conference June 3, 2010 Stephane Howze, MPH Vice President, Healthcare Division Harlem United

2 ER utilization has increased sharply nationwide (31% increase from 1995 to 2005).[1][1] Homeless individuals account for a high portion of ER use; they are three times more likely than the general population to use the emergency department and tend to visit the ER repeatedly.[2]-[3][2][3] Roughly 26% of New York City (NYC) populations live at or below 200% of the federal poverty line, with poverty rates being much higher in East and Central Harlem.[4][4] Homeless individuals often have limited access to healthcare/primary care, have poor health status, and high rates of co-morbidities due to multiple barriers to quality healthcareBackgroundBackground

3 Harlem United’s Response Integrated care Model - offer medical care that is truly integrated with other essential services in a culturally competent, supportive, healthy healing community that meets clients’ multiple needs A “one-stop-shop” approach - allows members to benefit from a wide array of services in areas of medical and dental care, Mental Health services, expressive therapies, and case management.

4 Harlem United – Who We Are COBRA Case Management Assessment, Intensive Case Management, Advocacy, Crisis Intervention Supportive Housing Programs Case Management, Primary Care Support, Treatment Education, Mental Health Services, Substance Use Counseling, Advocacy, Structured Socialization Mental Health Services Crisis Intervention, Individual and Group Psychotherapy, Medication Management, Expressive Therapies Testing Services ♦Rapid HIV testing ♦Innovative recruitment strategies ♦Evaluation of testing strategies ♦Connection to primary care services ♦Access to HIV care through ADAP enrollment ♦ Uptown Health Link Education and Training ♦HIV Education and Community Awareness events ♦African Immigrants Services ♦Black Men’s Initiative Delivery of CDC-sponsored effective behavioral interventions ♦Healthy Relationships ♦Many Men, Many Voices ♦Youth Space Evening Food & Nutrition Nutritional Assessment and Support, Treatment Education, Psycho-Social Support Women’s Housing (Scatter-Site) Transitional Housing (Scatter-Site) Permanent Congregate Housing Prevention Services Prevention Services Federally Qualified Health Center & Related Services Supportive Housing Programs Supportive Housing Programs Adult Day Health Center East Fully Bilingual (Spanish/English) Case Management, Treatment Education, Support Groups, Harm Reduction Counseling, Auricular Acupuncture, Primary Care Support Adult Day Health Center West Medical Care, Adherence Support, Nutrition Counseling, Substance Use Counseling, Structured Socialization, Pastoral Care, Expanded Syringe Access Program HUD Housing (Scatter-Site) HRA Housing (Scatter-Site) Dental Clinic Primary Care (Westside & Eastside) Emergency Congregate Housing (Foundation House North & South) Harlem United ♦Injection Drug User Care ♦Harm Reduction ♦Syringe Exchange ♦Testing and Linkage to Healthcare Healthcare for the Homeless Healthcare & related services for the homeless in Central & East Harlem Vocational Education Program The Blocks Project Innovative prevention initiative Targets neighborhoods with high HIV prevalence, not high-risk sub-groups HIV education, testing and connection to care Additional social services via partners Building Bridges Mental Health Program

5 Harlem United - What We Do Founded at height of first phase of AIDS epidemic: In the early development, Harlem United (HU) specifically served people living with HIV/AIDS (PLWH/As) who were homeless and/or suffering from mental illness and/or substance use. Agency of last resort for medically-underserved communities of color in Harlem. Part of community-based movement to care for PLWH/As: Founded to address lack of response from established providers; Responding to the unique personal, social, and institutional barriers to care in Harlem.

6 Harlem United – Healthcare Division ADHC Article 28 License 1997 Primary Care Amendment to Article 28 License 2000 Dental Amendment to Article 28 License 2003 El Faro Extension Clinic Open ADHC & PC 2006 FQHC Designation Homeless 2007 HIV FOCUSED CENTER OF EXCELLENCE MANAGING CHRONIC ILLNESS 2012 Psychological Services Amendment to Article 28 License 2009 ALL VULNERABLE PATIENTS WITH A MULTIPLICITY OF NEEDS

7 Harlem United – Healthcare & Related Services Community Case Management Assessment, Intensive Case Management, Advocacy, Crisis Intervention; VidaCare Case Management; Maintenance in Care Wellness Center Mental Health and Substance Use Services Crisis Intervention, Individual and Group Psychotherapy, Medication Management, Expressive Therapies Evening Food & Nutrition Nutritional Assessment and Support, Treatment Skills- based Education, Psycho-Social Support and Harm Reduction Healthcare & Related Services Adult Day Health Center East Fully Bilingual (Spanish/English) Case Management, Treatment Education, Support Groups, Harm Reduction Counseling, Auricular Acupuncture, Primary Care Support Adult Day Health Center West Medical Care, Adherence Support, Nutrition Counseling, Substance Use Counseling, Structured Socialization, Pastoral Care Primary Care Dental Clinic Federally Qualified Healthcare Center Healthcare services for the Homeless in Central and East Harlem

8 FQHC – Healthcare for the Homeless (HCH) The FQHC-H designation allowed us to expand services to homeless people in Central and East Harlem communities who are predominantly African American and Latino(a) adults, and have histories of substance use and/or mental illness. This shift is very much aligned with our original mission; both our traditional clients and our new homeless clients are primarily poor, Africa American and Latino(a) adults, have histories of substance use and/or mental illness. All have experienced problems accessing medical care and supportive services.

9 HCH Services – An Integrated Care Model Primary Care clinic (Westside & Eastside) GYN, Health Education, Directly Observed Therapy, Psychiatry services, Preventive Health Services, Management Of Chronic Conditions Dental Clinic - Diagnostic X-rays and Exams - Preventive Care - Emergency Care - Restorations -Endodontics -Prosthodontics -Periodontics - Oral Surgery - Referral to outside specialists for complex Surgical Procedures Mental Health and Substance Use Services Crisis Intervention, Individual And Group Psychotherapy, Medication Management, Expressive Therapies Other services Referrals, Outreach, and Case Management. Federally Qualified Health Center

10 HCH Goals To increase access and eliminate barriers to care for homeless individuals in Central and East Harlem neighborhoods To improve health outcomes of homeless individuals To triage homeless individuals in Central and East Harlem neighborhoods from Emergency Room to our FQHC through HCH program

11 Evaluating HCH Efficacy  An outcome study was conducted in 2009 to evaluate HCH efficacy  Study Question: Are there differences in frequency of ER visits among homeless clients who have been receiving HCH services and those who are new to HCH?

12Method Study Design: Cross-sectional study Outcome variable: Frequency of ER visits Sample - Baseline group: new HCH clients who had their first intake between January 1 – December 31, Follow up group: clients who have been receiving services provided by HCH, indicated by having at least two HCH visits between January 1 – December 31, Analysis T-test to determine whether or not there are any differences in frequency of ER visits among clients in baseline and follow-up groups

13 Results – Demographics distribution Both groups have similar demographics distribution

14 HCH: Diagnostic Distribution Results – Diagnosis distribution Both groups have similar chronic illness distribution

15 Results – Frequency of ER visits Despite the similar demographics and chronic illness distributions, we observed a significant difference in the number of ER visits among the baseline and follow up groups.

16 Results – Frequency of ER visits The difference in frequency of ER Visits among the baseline and follow-up groups could be attributed to comprehensive HCH interventions, as evident in the following findings: 100% of clients in the follow up group are engaged in Primary Care (PC) 33% are also engaged in Dental 30% are engaged in other types of services, such as COBRA Case Management, ADHC, Maintenance in Care, and Mental Health

17 Results – Frequency of ER visits Clients in the follow-up group have an average of three follow-up visits in The visit types range from: - PC follow-up - psychiatric visits - walk-in to get sick care - psychotherapy visits - etc Many of those visits would have been made to the Emergency Room had they not been engaged in HCH.

18Conclusions Despite the absence of longitudinal analysis, findings may be regarded as preliminary evidence of HCH efficacy in triaging homeless patients from ER to HCH The convenience of our integrated care model, the culturally appropriate safe atmosphere that we create and the way we treat clients with dignity and respect are what made the homeless population, despite their transient nature, come back to seek care and comfort in our clinic instead of utilizing the expensive Emergency Room.