1. 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

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

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

4. 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

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

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

7. Accessing info - Health & Homelessness Suzanne Zerger’s guides at: www.nhchc.orgwww.nhchc.org 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

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

9. 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

10. 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

11. 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

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

13. 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

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

15. 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

16. Baseline – Age / Gender Respite Care ControlP Value N=161N=64 Age4344 0.54 ¹ Gender 0.59 ² Male78% 81% Female22% 19% ¹ T-test² Pearson Chi-Square

17. 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

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

19. 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

20. Baseline –Use of Bureau Resources 6 Months Prior to Referral

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

22. Effect of Respite Care Health Utilization during year following referral RespiteControlP Value Inpatient Days3.48.10.002 ER Visits1.42.20.09 Clinic Visits6.76.00.60 - Controlling for Age, Gender, Race, Prior Utilization, Diagnosis

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

24. 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

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

26. 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

27. 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 (2001-02) Lister Hill Center for Health Policy (2002-03)

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

29. 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

30. 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

31. 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

32. 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

33. Unadjusted Results at 90 days CharacteristicRespite Own CareAMA Other Carep N13643341174 Readmission/Death 15%19%20%22%.57 Inpatient Days 1.01.21.41.7.35 Inpatient Charges $2522$2819$3722$3910.45 *At 90 days, deaths (N=7) were <5% of readmission/death outcomes (N=154).

34. Multivariable-Adjusted Results at 90 Days VariableOdds Ratio (95% CI) Respite 0.5 (0.3-0.9) *Logistic Regression adjusted also for Age, Sex, Race/Ethnicity, & Drug Abuse

35. 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).

36. 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. 1995 May 10;273(18):1450-6. 2 N Engl J Med. 1996 May 23;334(21):1349-55.

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

38. Conclusions Everything you need to write grants is on the web  www.nhchc.org www.nhchc.org 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)