Respite Care Research Update

1. Respite CareResearch 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.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 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

17. 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

18. Baseline – Diagnosis Respite Care Control P Value N=161 N=64 Diagnosis 0.07 ¹ Trauma 40% 23% HIV 27% 28% Infection 12% 14% Other 21% 34% ¹ Pearson Chi-Square

19. 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

20. Baseline –Use of Bureau Resources6 Months Prior to Referral

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

22. Effect of Respite CareHealth Utilization during year following referral - Controlling for Age, Gender, Race, Prior Utilization, Diagnosis

23. Effect on Inpatient use by Diagnosis I N P A T I E N T D A Y S P = 0.01 HIV InfectionTrauma Other

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, 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)

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. Discharged to Own Care (n=433) Respite Unit (n=136) Hospitalized Homeless 7/98-6/01 (n=784) Time to Readmission or Death Other Planned Care (n=174) Left AMA (n=41) Definition of Comparison Groups

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

34. Multivariable-Adjusted Results at 90 Days

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 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.

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 • 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)