Respite Care Research Update David Buchanan MD Head, Section of Social Medicine Stroger Hospital of Cook County National Healthcare for the Homeless Conference Portland, OR June 2006

Outline Why should I care about research? How can I access info on health and homelessness? Respite specific outcomes

Why care about Research? Grant writing Policy / Advocacy Evidence Based Medicine Quality Improvement

Quality Improvement resulting from Chicago Housing for Health Partnership Study of the Impact of Housing / Case Management 400 Chronically ill homeless people Case Managers work together across agencies Participants are in CHHP stay in CHHP Reduced barriers to accessing housing Exploration of harm reduction respite model Shift toward harm reduction permanent housing

Outline Why should I care about research? How can I access info on health and homelessness? Respite specific outcomes

Summary - Homelessness and Health Very sick Use a lot of services Die young

Accessing info - Health & Homelessness Suzanne Zerger’s guides at: A Preliminary Review of Literature: Chronic Medical Illness and Homeless Individuals Learning about Homelessness & Health in your Community: A Data Resource Guide Developing Outcome Measures to Evaluate HCH Services (61 pages) by Pat Post

Outline Why should I care about research? How can I access info on health and homelessness? Respite specific outcomes  Salt Lake City  Chicago  Boston

Descriptive Study It Takes a Village: A Multidisciplinary Model for the Acute Illness Aftercare of Individuals Experiencing Homelessness Gundlapalli, Hanks, Stevens, Geroso, Viavant, McCall, Lang, Bovos, Branscomb, Ainsworth Journal of Health Care for the Poor and Underserved, Volume 16, Number 2, May 2005

Respite Care Outcomes Project David Buchanan MD Cook County Bureau of Health Services / Rush University Bruce Doblin MD MPH Interfaith House Medical Director Theo Sai MD Pablo Garcia MD American Journal of Public Health, July 2006

Interfaith House / Chicago Outcomes Chicago’s primary respite care center Average length of stay: 45 days 40% of clients from Cook County Hospital Able to serve less than half of eligible referrals

Research Question Does respite care affect client’s future use of:  Hospital days,  Emergency Room visits,  Clinic Services?

Respite Care Outcomes Project Retrospective review of Cook County Bureau of Health Services admin data Subjects: All eligible clients referred for respite Time Period: October ‘98 - December 2000 Outcome: County Service use during next yr  Inpatient Days  ER Visits  Clinic Visits

Participants (N=225) 78% Male 73% African-American 8% Latino Diagnoses:  35% Trauma  28% HIV  13% Infection  24% Other

225 Referred by Cook County Hospital Oct 98 – Dec 2000 Respite Care Group 161 eligible and placed at Interfaith House Control Group 64 eligible, not placed due to lack of beds

Baseline – Age / Gender Respite Care ControlP Value N=161N=64 Age ¹ Gender 0.59 ² Male78% 81% Female22% 19% ¹ T-test² Pearson Chi-Square

Baseline – Race Respite Care ControlP Value N=161N=64 Race 0.05 ¹ AA75% 67% White/Other19% 16% Latino 6% 16% Other 1% 2% ¹ Pearson Chi-Square

Baseline – Diagnosis Respite Care ControlP Value N=161N=64 Diagnosis0.07 ¹ Trauma40%23% HIV27%28% Infection12%14% Other21%34% ¹ Pearson Chi-Square

Prior 6 Month - Resource Use Respite Care Control P Value¹ N=161N=65 Inpatient days 5.8, 2 (0, 8)5.3, 0 (0, 7)0.23 ED visits 1.5, 1 (0, 2)0.9, 0 (0, 1)0.02 Clinic visits 1.8, 0 (0, 2)1.8, 0 (0, 1)0.42 Note: numbers above are mean, median (25th, 75th percentile) ¹ Mann-Whitney

Baseline –Use of Bureau Resources 6 Months Prior to Referral

Results - Bureau Resource Use during year following referral P=0.002 NS Model controlled for Age, Gender, Race, Diagnosis, Prior use

Effect of Respite Care Health Utilization during year following referral RespiteControlP Value Inpatient Days ER Visits Clinic Visits Controlling for Age, Gender, Race, Prior Utilization, Diagnosis

Effect on Inpatient use by Diagnosis INPATIENT DAYSINPATIENT DAYS HIV Infection Trauma Other P = 0.01

Respite Care Costs Average respite costs: $3,476 / patient  Costs at Interfaith House: $79 / day  Average respite days: 44  Respite Cost per hospital day avoided: $706

Estimated Cost Savings Respite Cost per hospital day avoided: $706 Costs of a hospital day  AHRQ estimate: $1500 per day  Most are uninsured

Respite Care Outcomes Patients receiving respite care: Needed 4.7 fewer Hospital Days (58% reduction) Trend toward reduced ER visits (36% reduction) Had similar clinic use HIV patients had greatest reduction in hospital days Overall cost savings exceed respite costs

Hospital Discharge to a Homeless Medical Respite Program Prevents Readmission Stefan G. Kertesz, MD, MSc 1 ● Michael A. Posner, MS 2 James J. O’Connell, MD 3 ● Ashley Compton, BS 1 Stacy Swain, MPH 3 ● Michael Shwartz, PhD 2 ● Arlene S. Ash, PhD 2 1 University of Alabama at Birmingham ● 2 Boston University/ Boston Medical Center ● 3 Boston Health Care for the Homeless Program Support: Boston Health Care for the Homeless Program ( ) Lister Hill Center for Health Policy ( )

Design Subjects: Hospitalized homeless persons Groups: Post-hospital placement site 1º Outcome: Re-admission / death - 90 days 2º Outcomes: Inpatient days & Hospital charges

Study Sample  Retrospective study, administrative data  People who got into the study had…  Experienced a non-maternity medical/surgical hospitalization between 7/1/98-6/30/01  used an outpatient homeless health program  People were excluded for…  duplicate or unfound records  index admission for childbirth  died during index admission  re-hospitalized within one day

Definition of Comparison Groups Hospitalized Homeless 7/98-6/01 (n=784) Respite Unit (n=136) Discharged to Own Care (n=433) Other Planned Care (n=174) Left AMA (n=41) Time to Readmission or Death

Data Sources  Hospital Information System provided:  Inpatient discharge abstracts  Outpatient diagnoses, readmissions  Boston Health Care for the Homeless Program Databases  Massachusetts Registry of Vital Statistics

Adjustment for Potential Confounders  Age, Sex, Race-ethnicity  Drug and Alcohol Abuse  Index hospital length of stay  Illness burden, chart review of prior 6 months

Unadjusted Results at 90 days CharacteristicRespite Own CareAMA Other Carep N Readmission/Death 15%19%20%22%.57 Inpatient Days Inpatient Charges $2522$2819$3722$ *At 90 days, deaths (N=7) were <5% of readmission/death outcomes (N=154).

Multivariable-Adjusted Results at 90 Days VariableOdds Ratio (95% CI) Respite 0.5 ( ) *Logistic Regression adjusted also for Age, Sex, Race/Ethnicity, & Drug Abuse

Conclusions  Homeless patients placed in respite care had a 50% reduced odds of early readmission or death at 90 days  Other care environments (nursing homes) were not associated with a similar benefit  Inpatient days & charges also  for respite program up to 90 days.  Effects diminished over time (persistent trend).

Reduction in Hospitalizations 50-58% Respite Care 35% Ace-Inhibitors for Congestive Heart Failure 1 27% Carvedilol (β-Blocker) - Congestive Heart Failure 2 1 JAMA May 10;273(18): N Engl J Med May 23;334(21):

Research - Next Steps Health improvement Mortality reduction Detailed Cost analyses Randomized trials

Conclusions Everything you need to write grants is on the web  Salt Lake City paper / conference handouts for respite descriptions Chicago & Boston Studies show ↓ hospitalizations  50% reduction in next 90 days (Boston)  58% reduction in next year (Chicago)