Ryan Levy / Compromises
Henry Jones felt like he was at the bottom of the line in the summer of 1991.
There was no way out, he remembered, he thought. “I was praying and I was tired, but I didn’t see a way out.”
Jones had been homeless in Washington for 11 years, and the years had taken their toll. “I’m getting sicker and sicker,” he said. “I could feel my health deteriorating.
One hot June morning, Jones was in particularly severe shape, his legs aching, his stomach aching, and his arms trembling. A security guard had to take him from the hospital parking lot to the emergency department as he was barely standing.
The hospital did not want to accept him, but a social worker directed him to a place called Christ House, a homeless shelter that is too sick to be on the street or in a shelter but not sick enough to need care. at the hospital level.
Today, there are a growing number of programs such as Christ House that provide short-term medical care for the homeless, known as medical rest or rehabilitation care. The growth is fueled in part by a boost from Medicaid’s government programs to provide patient support to prevent avoidable health care use, such as emergency room visits.
“We’ve seen sick homeless people get worse and worse who were on the streets,” said Dr. Janel Gocheus, who started the 34-bed facility in 1985. So we just wanted to have a place to come and take care of them. “
By the time Henry Jones arrived in 1991, Christ House was hosting more than 300 people a year.
“I couldn’t believe what I saw,” Jones said, remembering his first day. “I slept in a nice, clean bed. I got good food to eat. The nurses and doctors were so worried. They just wanted me to get better, and I could see that.
Medical leave is growing
Christ House was one of the first medical recreation centers and is now one of 133 programs distributed in 37 states and Washington, DC. All of them offer homeless people a safe place to recover from surgery or other acute illness, learn to manage a chronic condition and get help finding a permanent home.
But the programs are unregulated and unlicensed and often look incredibly different, according to Julia Dobbins, director of medical leave at the National Homeless Health Council.
The most common situation is a homeless shelter – a few beds or a room separated by a nurse who comes to check once a day. Others, such as Christ House, have their own building and include full-service kitchens, social spaces, examination rooms and 24-hour medical care.
In the last seven years, the number of medical holiday homes has more than doubled due to many factors.
First, the number of homeless people is growing every year from 2016 to 2020, reaching nearly 600,000. The homeless population is also aging and sick. Research shows that homeless people in their 50s are in poorer health than people in their 70s who have a place to live, and half of older homeless people are over 50.
At the same time, doctors, health officials and state and federal politicians have begun to accept that non-medical factors such as housing affect people’s well-being and that the health industry needs to do something about it – such as medical leave.
Private Medicaid plans to stimulate growth
Perhaps the most surprising driver of the growth of medical leave is the interest of managed care organizations – private insurance companies, which cover 7 out of 10 people in Medicaid.
Most medical vacation programs have multiple sources of funding. Hospitals, philanthropy, and state and local governments have historically been the most common, but about 1 in 3 programs now receive some funding from Medicaid plans.
Dobbins said it began when the Affordable Care Act allowed 38 states and Washington to expand Medicaid to low-income adults without children by bringing thousands of previously homeless people into Medicaid.
Ryan Levy / Compromises
Many government Medicaid programs are simultaneously putting pressure on managed care organizations to reduce costly care that can be avoided by forcing more insurers to consider medical leave.
One example is AmeriHealth Caritas DC, one of three managed care plans in Washington. In 2016, Washington’s Medicaid program began to increase insurers’ pay if they failed to reduce hospital readmission and unnecessary emergency room visits.
AmeriHealth estimates that it provides Medicaid benefits to about 3,500 homeless people, some of whom have used a lot of hospital and emergency services. The company calculated the figures and was convinced that medical leave could improve people’s health, help businesses avoid financial sanctions and save up to $ 200,000 a year.
From there, they partnered with other local organizations to get started Nadezhda has a home, two new medical facilities for recreation with eight beds, which opened in 2019 and have so far served 62 homeless men.
“Thank God for this place,” said Wayne Gaddis, 58, who came to Hope Has a Home after a spinal operation. “If I hadn’t been here, I would have been on the street, probably on drugs again, killing myself slowly, not taking my medication, not caring because I feel that no one else cares. But this place gives me new hope. New life.”
The need for more evidence
There are about 20 peer-reviewed articles on medical leave that Dobbins of the National Homeless Health Council and her team recently reviewed. This study strongly suggests that people who take medical leave spend less time in the hospital, are less likely to be re-admitted to the hospital, and are more likely to use first aid.
But much of the existing evidence is self-published by medical respite programs, and no one has conducted a strictly randomized controlled trial in the United States
“Unfortunately, there is not as much literature in this area as we would like to have,” Dobbins said.
And there is even less evidence that medical leave is likely to save insurers money.
Paying a few hundred dollars a day to send someone on medical leave is certainly cheaper than paying thousands of dollars a night to stay in the hospital. But it can also prolong someone’s life and reveal chronic conditions that will require years of treatment.
“We can’t underestimate how sick he is [homeless] people are, “Dobbins said.
By way of example, AmeriHealth Caritas DC says the first 11 people sent to Hope Has A Home went to the emergency department less. But their primary care visits skyrocketed, which helped increase overall care costs by 75%.
This is only a small sample and AmeriHealth remains committed to the medical holiday with plans to launch two facilities for homeless women next year.
“Everything we do may not necessarily lead to cost savings,” said Dr. Karin Wills, chief medical officer of CareFirst, another Washington-based organization that began paying for medical leave in 2021. “Important is, but not our main engine “
Impulse and barriers to politics
Politicians in Washington, Minnesota, Colorado and New York are exploring how they can expand access to medical leave through Medicaid. But the main obstacle remains.
The federal centers for Medicare and Medicaid services are prohibited from paying for “room and food”, which prevents medical leave from being covered by Medicaid, as well as other services such as visiting a doctor or staying in a nursing home.
Managed care organizations must enter into individual contracts with each health care provider, and the money they spend on vacation is not included in their annual contract negotiations with Medicaid government programs to determine how much state and federal money they receive.
In 2022, California became the first state to receive a CMS exemption, allowing medical delays to cover benefits. Utah is in the process of getting its own waiver, further proof that the CMS is open to this experiment.
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Leisure providers, insurance companies, advocates and politicians agreed that a bigger change in CMS policy could open the door to greater medical leave. But even if that happens, it is likely to affect only part of the country’s nearly 600,000 homeless people.
“We will not end this crisis with just medical beds,” said Julia Dobbins. “Medical care for rest is not a home.”
Forty percent of Christ House residents have been discharged to or from the shelter in the past three years. He also left a similar stake in Hope Has a Home without finding a stable place to live.
The lack of affordable housing forces holiday homes to choose between putting someone back home or keeping them in a bed that someone else needs.
“We should always talk about affordable access for homeless people,” Dobbins said. “Otherwise, we will simply continue to talk about developing more and more leisure programs. And while I’m here to support them, that’s not my long-term goal. “
This story is produced by Compromisesa podcast exploring our confusing, expensive, and often counter-intuitive healthcare system.