1. Strange Bedfellows: Thoughts on the Once and Future Role of Hospitals and Academic Medical Centers in the Care of Homeless Persons James J. O’Connell, M.D. Boston Health Care for the Homeless Program Departments of Medicine, Massachusetts General Hospital and Boston Medical Center Presented at National Alliance to End Homelessness Conference July 2006

2. O'Connell/BHCHP BHCHP Basic Goals 1984 Establish a health services care delivery model to provide continuity of care from shelter and street to hospital; Provide care through multidisciplinary outreach teams; Establish the capacity to meet the needs of homeless individuals for home-type respite care

3. O'Connell/BHCHP

4. City of Boston Annual Census, 12/13/2004 Among 3,944 homeless individuals identified on a single night census 888 (22%) in medical/mental health facilities – 14 emergency departments –286 medical hospitals – 84 medical respite beds (McInnis House) –225 detox –279 mental health hospitals/inpatient programs

5. O'Connell/BHCHP MGH Mission, 1810 “When in distress, every man becomes our neighbor…It is unnecessary to urge these truths on those who are already in the habit of cherishing them…The relief to be afforded to the poor, in a country so rich as ours, should perhaps be measured only by their necessities.” From the “Circular Letter” of 1810 of John C. Warren and James Jackson leading to establishment of the Massachusetts General Hospital

6. O'Connell/BHCHP

8. MGH/BHCHP Pilot Project 26 random MGH charts reviewed of persons admitted to BMH during FY 2005 Ground rules: team or RN case manager describe patient as ready for D/C Number of days from that point until admission to BMH Conclusion: 48% potential reduction in ALOS with ready access to respite beds (i.e. no waiting list) Summary of results: –336 total days –ALOS 12.9 days –159 “excess” days

9. O'Connell/BHCHP MGH/BHCHP Pilot Study From March through June, 19 admissions “fast tracked” from MGH to BMH –16 inpatient service – 3 directly from EW Results: –110 total days – 75 days “saved” Days “saved” determined by MGH RN case managers

10. O'Connell/BHCHP Other Observations Admission from MGH EW to BMH, discharged to Housing First after 100 days in respite care -45 MGH EW visits in past year - 0 MGH EW visits since BMH admission and housing (6 months) 5 persons currently at BMH with LOS greater than 90 days -4/5 admitted directly from MGH

11. O'Connell/BHCHP BHCHP and ED High Utilizers Boston, 2005 MGH: 16 BHCHP patients among top 25 Accounted for a total of 344 ED visits –35 visits (10%) resulted in hospital admission –309 visits (90%) discharged from ED

12. O'Connell/BHCHP Hospitals and Homeless Persons: What are the numbers??? 14,200 BHCHP adult patients seen in 2004-5 matched with Partners HealthCare database: 3283 common patients 2090 (15%) seen at MGH 1148 (8%) seen at BWH –only 259 of these 3283 served at both MGH/BWH

13. O'Connell/BHCHP BHCHP and Partners Healthcare 2004-2005 Hospital Admissions : MGH: 561 persons, 1114 admissions ALOS 7.5 days BWH: 269 persons, 506 admissions ALOS 4.2 days (OB-GYN)

14. O'Connell/BHCHP BHCHP and Partners’ Healthcare 2004-2005 Emergency Room Use: MGH: 1,515 persons (73% of 2,090) had total of 5,539 ED visits Average # ED visits: 3.7 865 (16%) of ED visits resulted in admission BWH: 952 persons (83% of 1,148) had total of 2,836 ED visits Average # ED visits: 3.0 319 (11%) of ED visits resulted in admission

15. O'Connell/BHCHP BHCHP and ED High Utilizers Boston, 2005 Boston Medical Center 23/25 (92%) (Boston University Medical School) New England Medical Center14/25 (56%) (Tufts Medical School) Massachusetts General Hospital16/25 (64%) (Harvard Medical School)