Justifying A Respite:The Schenectady Experience

Erin Simao, MPHAlexander Simao, Jr., DO, MPH

National Health Care for the Homeless ConferenceMay 23, 2019

“The City That Lights and Hauls the World”

Where do you go in Schenectady if you’re experiencing homelessness?The Evangeline Booth Miracle Home

YWCA

Bethesda House

Peter Young

Safe Inc

City Mission: 76 bed Men’s shelter, emergency shelter

New York State Medicaid Redesign: DSRIP

Overarching goal:

Decrease avoidable hospital use by 25% over 5 years

*Driving communities to identify opportunities for improved care coordination and delivery, and ultimately patient outcomes

City Mission opportunity

Between June 2017 and May 2018, roughly 140 calls to 911 from Men’s shelter (What were the calls for?)

Initiatives:

Telemedicine program

Health Navigators to connect to insurance and primary care

With support from DSRIP funding...

Formation of Medical Respite in Capital District

● Social Work & Sheltering Model● Accepted referrals from the Capital District

○ DSS Reimbursement Model for Shelter Bed○ Based on County of Residence○ VNS also County Based

Schenectady County elected to no longer reimburse for beds outside of the County

Difficulty in obtaining Schenectady VNS services

“Let’s do the same thing here!”

Plan: To copy the exact design with a location in Schenectady.

Process: Pick the location, determine the bed rate, then determine the services and the partners. Then talk to the patients.

Result: No respite. No agreement on nightly rate. No County funding for Schenectady County residents.

‘What’s in it for us?”

Back to the data...

Homeless Admission Data January 2013 - June 2018

Goals:

● Determine the extent of admissions of homeless adults at Ellis Hospital to help reflect capacity

● Review common diagnoses for admission to determine health needs at a potential respite (VNS, PT/OT)

● Look at the extent of readmissions among this population (DSRIP and Respite Goals)

Homeless Admission Data

Inclusion Criteria:Ellis Hospital Inpatient Observations/Admissions from Jan 2013 - June 2018 (438 Bed Community Hospital)

Homelessness defined as selection of: “Homeless” or “Shelter” on CM or SW Assessment

Exclusion Criteria:Length of stay < 2 Days (Removed 168)No Diagnosis (Removed 16)N = 306

Homeless Admission Data: The Where

Homeless Admission Data: The Why

Infection Type n Percent

Skin and Soft Tissue 26 31.0

“Sepsis” 13 15.5

Respiratory 12 14.3

GI 12 14.3

Bone (Osteo) 8 9.5

Other 13 15.6

Homeless Admission Data: The Who239 Unique Adults

The majority (94.1%) had 1-2 admissions over this timeframe

14 Individuals admitted 3 or more times (5.9%)

Highest Number of Admissions: 926-28 yo Male2 for Opioid Overdose, 6 for Alcohol Withdrawal, & 1 for

Rhabdomyolysis for a total of 111 Hospital Days

Issue: Homeless “Admission” vs Person Experiencing Homelessness

Homeless Admission Data: The Who602 - CELLULITIS W MCC

● Ellis Medicare Volume: 18● Average Covered Charge: $29,828.33● Average Total Payment: $8,845.33

Average Cost Hospital Bed Per Day (2017)1

● NYS Nonprofit hospitals — $2,514● Estimate: $123,186

39 yo MaleHospitalized for 49 Days

Dx: T9-T10 MRSA Vertebral OsteomyelitisHx: IV Drug Use, “Chronic Pain”

Hospital Course: Initially transferred to AMC then transferred to Ellis. MRI, consults from ID and Neurosurgery (at both locations). Biopsy at AMC

Completed 8 weeks of IV Vancomycin INPATIENT.Weekly lab evaluation.

Discharged “home” with two weeks of Doxycycline.New PCP on discharge.“Will need referral for pain management” Not started on MAT inpatient.

CM Notes: “Patient is here receiving LT IV abx therapy as the need is not able to be met in the community.” “Will be living with his friend.”Referral to outpatient rehab.

Homeless Admission Data: What We Know

● We Admit our own● Acute > Chronic

○ What do we do about Alcohol?○ What about chronic diseases?

● Potential Needs○ IV Antibiotics, Physical Therapy a Must

● Cost Savings Potential○ But what about readmissions

● How do we define Homelessness?○ Who are we missing?○ Do we use the DSS definition?

Beyond a Respite...

Shelter Telemedicine Findings

Over the Period of October 1, 2018 to May 15, 2019:

57 Calls to Telemedicine Service with 43 unique individuals

40 Calls (70.2%) were for medication refills13 Calls (22.8%) were for acute illnesses2 Urgent Care Referrals and 1 Specialist Referral

Being used as a stopgap until established with primary care

*Points to opportunity to collaborate on re-entry front

Assess existing resources

Known Resources:

One hospital system2 major Medicaid-serving primary care practicesMental HealthSubstance Abuse services

Residency Clinics at City Mission and Bethesda House

Assess existing needs

In the process of conducting a survey of homeless individuals

Questions cover:

- Chronic disease burden- Health behaviors- Hospital utilization- Primary care utilization- Post-discharge concerns- Barriers to accessing primary care and behavioral health

References & Contact Information

1. Average hospital expenses per inpatient day across 50 stateshttps://www.beckershospitalreview.com/finance/average-hospital-expenses-per-inpatient-day-across-50-states.html

Erin Simao, MPHEmpower Health, City Mission of Schenectadyesimao@schenectadyworks.com

Alex Simao, DO, MPHEllis Medicine FM Residencyasimao08@gmail.com