Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations

National Overview of Nonprofit Hospitals' Community Benefit Programs to Address Housing

BACKGROUND

Housing is a critical social determinant of health that can be addressed through hospital-supported community benefit programming.

OBJECTIVES

To explore the prevalence of hospital-based programs that address housing-related needs, categorize the specific actions taken to address housing, and determine organizational and community-level factors associated with investing in housing.

RESEARCH DESIGN

This retrospective, cross-sectional study examined a nationally representative dataset of administrative documents from nonprofit hospitals that addressed social determinants of health in their federally mandated community benefit implementation plans. We conducted descriptive statistics and bivariate analyses to examine hospital and community characteristics associated with whether a hospital invested in housing programs. Using an inductive approach, we categorized housing investments into distinct categories.

MEASURES

The main outcome measure was a dichotomous variable representing whether a hospital invested in one or more housing programs in their community.

RESULTS

Twenty percent of hospitals invested in one or more housing programs. Hospitals that addressed housing in their implementation strategies were larger on average, less likely to be in rural communities, and more likely to be serving populations with greater housing needs. Housing programs fell into 1 of 7 categories: community partner collaboration (34%), social determinants of health screening (9%), medical respite centers (4%), community social determinants of health liaison (11%), addressing specific needs of homeless populations (16%), financial assistance (21%), and targeting high-risk populations (5%).

CONCLUSIONS

Currently, a small subset of hospitals nationally are addressing housing. Hospitals may need additional policy support, external partnerships, and technical assistance to address housing in their communities.

Hospital Readmissions Among Patients Experiencing Homelessness: An Electronic Health Record Data Study

BACKGROUND

Population-level tracking of hospital use patterns with integrated care organizations in patients experiencing homelessness has been difficult. A California law implemented in 2019 (Senate Bill 1152) aimed to ensure safety for this population after discharge from the hospital by requiring additional documentation for patients experiencing homelessness, which provides an opportunity to evaluate hospital use by this population.

METHODS

In a large integrated health system in California, patients experiencing homelessness were identified through documentation change requirements associated with this law and compared with a matched group from the general population.

RESULTS

Patients experiencing homelessness had increased rates of hospital readmission after discharge compared to the general population matched on demographics and medical comorbidity in 2019 and 2020. Any address change in the prior year for patients was associated with increased odds of emergency department readmission. Patients experiencing homelessness, both enrolled in an integrated delivery system and not, were successfully identified as having higher readmission rates compared with their housed counterparts.

CONCLUSION

Documentation of housing status following Senate Bill 1152 has enabled improved study of hospital use among those with housing instability. Understanding patterns of hospital use in this vulnerable group will help practitioners identify timely points of intervention for further social and health care support.

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA

CONTEXT

Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness.

METHODS

Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories.

FINDINGS

Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period.

CONCLUSIONS

While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

"More than just checking the box": community-based organizations on their role in Medicaid redesigns

New York and Massachusetts 1115 Medicaid demonstration waivers aimed to prioritize social determinants of health and engage community-based organizations to improve health outcomes. This is an evaluation of community-based organizations' public comments regarding their participation in social services delivery within the 1115 waivers. Both states solicited public comments on waiver implementation to date and potential improvements. The research team extracted all publicly available comments (n = 359) made by direct service providers between November 2016 and April 2019. The sample was then limited to only comments that discussed social service provision and health care-social service partnerships (n = 58). Findings are presented in 2 stages: (1) concerns regarding delivery system reform incentive payments funding levels, timing, and flow and (2) perspectives on how states and Medicaid administrators could improve health care-community organization relationships. Resource-dependent, community-based organizations protested insufficient funding. Additional comments identified specific design, structure, and implementation aspects of the 1115 waiver that could improve partnerships. Despite 1115 waivers prioritizing social service integration, community-based organizations still feel underfunded and disenfranchised. Aligning with health care standards requires significant time and effort. Given resource constraints, the state must facilitate these investments. Community organizations' feedback can also offer guidance on waiver strategies in other states.

Establishing Academic Homes for Homelessness: A Call to Action

Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.

Health Care of People Experiencing Homelessness: Part I

Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.

Health & Housing in Delaware:: Matching Medicaid Claims and Encounters and the Community Management Information System Databases

This study draws upon data from two databases: claims and encounters that were reimbursed by the state's Division of Medicaid and Medical Assistance (DMMA) and the Homeless Management Information System (HMIS) database that collects homeless services data on individuals experiencing homelessness. Records from both sets are matched to identify 838 adults who both experienced homelessness and were Medicaid eligible in 2019, and to select, through propensity score matching, an equal set of control observations who were similarly Medicaid-eligible but had no record of homelessness. Outcomes are compared based upon scores on the Charlson Elixhauser Comorbidity index, incidence of substance use disorder, inpatient, emergency department, and outpatient visits, and inpatient, emergency department, and outpatient costs. Using ordinary least squares regression models, we estimate homelessness (as indicated by use of homeless services) to be associated with excess costs of $4,611 (non-chronic homelessness) to $5,218 (chronic homelessness) per person over the course of 2019, compared to similar Medicaid enrollees who were housed.

Health Care Utilization among Homeless-Experienced Adults Who Were Seen by a Mobile Addiction Health Clinic in Boston, Massachusetts: A Quasi-Experimental Study

Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; pdiff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; pdiff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; pdiff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.

A Medicaid Benefit for Health-Related Social Needs

This Viewpoint explores a recent advancement to improve outcomes and reduce costs within state Medicaid programs, Section 1115 demonstration waivers.

Predicting Homelessness Among U.S. Army Soldiers No Longer on Active Duty

INTRODUCTION

The ability to predict and prevent homelessness has been an elusive goal. The purpose of this study was to develop a prediction model that identified U.S. Army soldiers at high risk of becoming homeless after transitioning to civilian life based on information available before the time of this transition.

METHODS

The prospective cohort study consisted of observations from 16,589 soldiers who were separated or deactivated from service and who had previously participated in 1 of 3 baseline surveys of the Army Study to Assess Risk and Resilience in Servicemembers in 2011-2014. A machine learning model was developed in a 70% training sample and evaluated in the remaining 30% test sample to predict self-reported homelessness in 1 of 2 Longitudinal Study surveys administered in 2016-2018 and 2018-2019. Predictors included survey, administrative, and geospatial variables available before separation/deactivation. Analysis was conducted in November 2020-May 2021.

RESULTS

The 12-month prevalence of homelessness was 2.9% (SE=0.2%) in the total Longitudinal Study sample. The area under the receiver operating characteristic curve in the test sample was 0.78 (SE=0.02) for homelessness. The 4 highest ventiles (top 20%) of predicted risk included 61% of respondents with homelessness. Self-reported lifetime histories of depression, trauma of having a loved one murdered, and post-traumatic stress disorder were the 3 strongest predictors of homelessness.

CONCLUSIONS

A prediction model for homelessness can accurately target soldiers for preventive intervention before transition to civilian life.

A Community Partnership to House and Care for Complex Patients with Unstable Housing

Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.

Comparison of Childbirth Delivery Outcomes and Costs of Care Between Women Experiencing vs Not Experiencing Homelessness

IMPORTANCE

Women and families constitute the fastest-growing segments of the homeless population. However, there is limited evidence on whether women experiencing homelessness have poorer childbirth delivery outcomes and higher costs of care compared with women not experiencing homelessness.

OBJECTIVE

To compare childbirth delivery outcomes and costs of care between pregnant women experiencing homelessness vs those not experiencing homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 15 029 pregnant women experiencing homelessness and 308 242 pregnant women not experiencing homelessness who had a delivery hospitalization in 2014. The study used statewide databases that included all hospital admissions in 3 states (ie, Florida, Massachusetts, and New York). Delivery outcomes and delivery-associated costs were compared between pregnant women experiencing homelessness and those not experiencing homelessness cared for at the same hospital (analyzed using the overlap propensity-score weighting method and multivariable regression models with hospital fixed effects). The Benjamini-Hochberg false discovery rate procedure was used to account for multiple comparisons. Data were analyzed from January 2020 through May 2020.

EXPOSURE

Housing status at delivery hospitalization.

MAIN OUTCOMES AND MEASURES

Outcome variables included obstetric complications (ie, antepartum hemorrhage, placental abnormalities, premature rupture of the membranes, preterm labor, and postpartum hemorrhage), neonatal complications (ie, fetal distress, fetal growth restriction, and stillbirth), delivery method (ie, cesarean delivery), and delivery-associated costs.

RESULTS

Among 15 029 pregnant women experiencing homelessness (mean [SD] age, 28.5 [5.9] years) compared with 308 242 pregnant women not experiencing homelessness (mean [SD] age, 29.4 [5.8] years) within the same hospital, those experiencing homelessness were more likely to experience preterm labor (adjusted probability, 10.5% vs 6.7%; adjusted risk difference [aRD], 3.8%; 95% CI, 1.2%-6.5%; adjusted P = .03) and had higher delivery-associated costs (adjusted costs, $6306 vs $5888; aRD, $417; 95% CI, $156-$680; adjusted P = .02) compared with women not experiencing homelessness. Those experiencing homelessness also had a higher probability of placental abnormalities (adjusted probability, 4.0% vs 2.0%; aRD, 1.9%; 95% CI, 0.4%-3.5%; adjusted P = .053), although this difference was not statistically significant.

CONCLUSIONS AND RELEVANCE

This study found that women experiencing homelessness, compared with those not experiencing homelessness, who had a delivery and were admitted to the same hospital were more likely to experience preterm labor and incurred higher delivery-associated costs. These findings suggest wide disparities in delivery-associated outcomes between women experiencing homelessness and those not experiencing homelessness in the US. The findings highlight the importance for health care professionals to actively screen pregnant women for homelessness during prenatal care visits and coordinate their care with community health programs and social housing programs to make sure their health care needs are met.

Pandemic Pause: Systematic Review of Cost Variables for Ambulatory Care Organizations Participating in Accountable Care Organizations

Ambulatory health care provider organizations participating in Accountable Care Organizations (ACOs) organizations assume costs beyond typical practice operations that are directly associated with value-based care initiatives. Identifying these variables that influence such costs are essential to an organization’s financial viability. To enable the U.S. healthcare system to respond to the COVID-19 pandemic CMS issued blanket waivers that permit enhanced flexibility, extension, and other emergency declaration changes to ACO reporting requirements through the unforeseen future. This relaxation and even pausing of reporting requirements encouraged the researchers to conduct a systematic review and identify variables that have influenced costs incurred by ambulatory care organizations participating in ACOs prior to the emergency declaration. The research findings identified ACO-ambulatory care variables (enhanced patient care management, health information technology improvements, and organizational ownership/reimbursement models) that helped to reduce costs to the ambulatory care organization. Additional variables (social determinants of health/environmental conditions, lack of integration/standardization, and misalignment of financial incentives) were also identified in the literature as having influenced costs for ambulatory care organizations while participating in an ACO initiative with CMS. Findings can assist ambulatory care organizations to focus on new and optimized strategies as they begin to prepare for the post-pandemic resumption of ACO quality reporting requirements once the emergency declaration is eventually lifted.

Addressing Major Health Disparities Related to Coronavirus for People With Behavioral Health Conditions Requires Strength-Based Capacity Building and Intentional Community Partnership

Far from being an equalizer, as some have claimed, the COVID‐19 pandemic has exposed just how vulnerable many of our social, health, and political systems are in the face of major public health shocks. Rapid responses by health systems to meet increased demand for hospital beds while continuing to provide health services, largely via a shift to telehealth services, are critical adaptations. However, these actions are not sufficient to mitigate the impact of coronavirus for people from marginalized communities, particularly those with behavioral health conditions, who are experiencing disproportional health, economic, and social impacts from the evolving pandemic. Helping these communities weather this storm requires partnering with existing community‐based organizations and local governments to rapidly and flexibly meet the needs of vulnerable populations.