Respite Care Research Update David Buchanan MD Head, Section of Social Medicine Stroger Hospital of...
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Transcript of Respite Care Research Update David Buchanan MD Head, Section of Social Medicine Stroger Hospital of...
Respite CareResearch Update
David Buchanan MDHead, Section of Social MedicineStroger 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: www.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
Outline
Why should I care about research? How can I access info on health and homelessness? Respite specific outcomes
Salt Lake CityChicagoBoston
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 MDPablo 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 HospitalOct 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 Control P Value
N=161 N=64
Age 43 44 0.54 ¹
Gender 0.59 ²
Male 78% 81%
Female 22% 19%
¹ T-test ² Pearson Chi-Square
Baseline – Race Respite Care Control P Value
N=161 N=64
Race 0.05 ¹
AA 75% 67%
White/Other 19% 16%
Latino 6% 16%
Other 1% 2%
¹ Pearson Chi-Square
Baseline – Diagnosis
Respite Care Control P ValueN=161 N=64
Diagnosis 0.07 ¹
Trauma 40% 23%
HIV 27% 28%
Infection 12% 14%
Other 21% 34%¹ Pearson Chi-Square
Prior 6 Month - Resource Use
Respite Care Control P Value¹
N=161 N=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 Resources6 Months Prior to Referral
0
1
2
3
4
5
6
Respite CareControl
Results - Bureau Resource Use during year following referral
0123456789
Respite CareControl
P=0.002
NS
NS
Model controlled for Age, Gender, Race, Diagnosis, Prior use
Effect of Respite Care Health Utilization during year following referral
Respite Control P Value
Inpatient Days 3.4 8.1 0.002
ER Visits 1.4 2.2 0.09
Clinic Visits 6.7 6.0 0.60
- Controlling for Age, Gender, Race, Prior Utilization, Diagnosis
Effect on Inpatient use by Diagnosis
INPATIENT DAYS
-25
-20
-15
-10
-5
0
5
10
HIV Infection Trauma Other
P = 0.01
Respite Care Costs
Average respite costs: $3,476 / patient
Costs at Interfaith House: $79 / dayAverage respite days: 44Respite Cost per hospital day avoided: $706
Estimated Cost Savings
Respite Cost per hospital day avoided: $706
Costs of a hospital dayAHRQ estimate: $1500 per dayMost 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, MSc1 ● Michael A. Posner, MS2
James J. O’Connell, MD3 ● Ashley Compton, BS1
Stacy Swain, MPH3 ● Michael Shwartz, PhD2 ● Arlene S. Ash, PhD2
1University of Alabama at Birmingham ● 2Boston University/ Boston Medical Center ● 3Boston Health Care for the Homeless Program
Support: Boston Health Care for the Homeless Program (2001-02) Lister Hill Center for Health Policy (2002-03)
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)
Hospitalized Homeless 7/98-6/01
(n=784)
Respite Unit (n=136)Respite Unit (n=136)
Discharged to Own Care (n=433)
Discharged to Own Care (n=433)
Other Planned Care (n=174)Other Planned Care (n=174)
Left AMA (n=41)Left AMA (n=41)
Time to Readmission or
Death
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
Characteristic RespiteOwn Care AMA
Other Care p
N 136 433 41 174
Readmission/Death 15% 19% 20% 22% .57
Inpatient Days 1.0 1.2 1.4 1.7 .35
Inpatient Charges $2522 $2819 $3722 $3910 .45
*At 90 days, deaths (N=7) were <5% of readmission/death outcomes (N=154).
Multivariable-Adjusted Results at 90 Days
Variable Odds Ratio (95% CI)
Respite 0.5 (0.3-0.9)
*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 Failure1
27% Carvedilol (β-Blocker) - Congestive Heart Failure2
1JAMA. 1995 May 10;273(18):1450-6.
2 N Engl J Med. 1996 May 23;334(21):1349-55.
Research - Next Steps
Health improvement Mortality reduction Detailed Cost analyses Randomized trials
Conclusions
Everything you need to write grants is on the webwww.nhchc.org
Salt Lake City paper / conference handouts for respite descriptions
Chicago & Boston Studies show ↓ hospitalizations50% reduction in next 90 days (Boston)58% reduction in next year (Chicago)