MEDICAL RESPITE IN NEW YORK CITY

MEDICAL RESPITE IN NEW YORK CITY ROSA M. Gil, DSW Founder, President & CEO Comunilife, Inc. 14th Annual New York State Supportive Housing Conference June 5, 2014

INTRODUCTION National attention is increasingly focused on homelessness and hospital admissions; readmissions; and Emergency Department utilization. Throughout the Country, many Medical Respite Programs have been developed to stabilize homeless patients medical and social needs after hospital discharged in short term basis. Demonstrated cost savings from Medical Respite Programs.

INTRODUCTION (CONTINUATION) New York State Medical Redesign Team (MRT) has focused attention on patients with high utilization of hospital impatient and Emergency Departments including homeless individuals. Comunilife and Montefiore Hospital Care Management Organization (CMO) developed the first New York City Medical Respite program in 2011.Bronx Lebanon Hospital joined the program in 2012. This presentation will discuss the development of this Respite Program and preliminary data.

COMUNILIFE MEDICAL RESPITE PROGRAM Today, NYC hospitals are reimbursed at a lower daily rate, or are not reimbursed at all, when patients remain in the hospital after they are medically cleared for discharge. Under the Affordable Care Act, hospitals are financially penalized for not discharging medically cleared patients who remain in the hospital due to their inability to secure stable housing and nurse themselves through convalescence. Further, hospitals are penalized for re admissions of patients within 30 days of discharged.

COMUNILIFE MEDICAL RESPITE PROGRAM (CONTINUATION) The purpose of the Respite Program is to provide safe, transitional housing for patients who are medically cleared and do not require hospitalization but cannot be discharged to a stable home or shelter. Clients access medical care and other supportive services.

COMUNILIFE MEDICAL RESPITE PROGRAM (CONTINUATION) Total number of beds: 10 Admission Criteria to the Respite Program The following admission criteria were developed jointly by Comunilife and participating hospitals: Lack suitable housing

COMUNILIFE MEDICAL RESPITE PROGRAM (CONTINUATION) Need an environment in which to prepare for or recover from medical procedures such as surgery, chemotherapy, radiation, endoscopies, etc. Be independent in Activities of Daily Living (ADL) with the ability to dress and transfer and ambulate independently or with mechanical assistance such as wheelchair, crutches or cane. Be psychiatrically stable enough to accept and receive care and not interrupt the care of others. Be sick enough to need more than an emergency shelter bed for the night.

COMUNILIFE MEDICAL RESPITE PROGRAM (CONTINUATION) Not be sick enough to require hospital level care or other medical care (nursing home, psychiatric in patient admission, rehabilitation hospital). Have a condition with an identifiable end point of care for discharge. Patients can be discharged to the Respite Program without Program Referral Unit (PRU) processing Patients will be accepted regardless of insurance or legal status

COMUNILIFE MEDICAL RESPITE PROGRAM (CONTINUATION) Patients must be at least 21 years old Patients must agree to program rules and regulations Patients requiring IV hydration will be assessed on a case to case basis.

REFERRAL PROCEDURE Discharge planning is expected to begin as soon as the patient is admitted to the hospital. The hospital Social Worker calls the Respite Coordinator to make referral and the Coordinator provides a bedside assessment, usually within 24 hours of the referral. The Director of Respite Care will make the decision for acceptance into the program based on the above admission criteria and discussion with the hospital social worker and the patient. Once accepted, the Coordinator will arrange for transportation to the Respite Program.

REFERRAL PROCEDURE (CONTINUATION) The hospital provides to the Program, with patient consent, the following information: Initial History and Physical and Discharge Summary. Psychiatric and substance abuse consultation All pertinent social service information

REFERRAL PROCEDURE (CONTINUATION) Follow up appointments for specialty care, if applicable TB status or other ID disclosure (MRSA, VRE, etc) Public Communicable Disease Disclosure Referral for Home-Care

REFERRAL PROCEDURE (CONTINUATION) Provide 30 days of medication for patients with chronic disease and the antibiotics related to the hospitalization diagnosis. Identify estimated length of time respite care will be needed. It should be noted that significant time was spent working with social workers and discharge planning staff to understand and use the Respite Program.

SERVICES PROVIDED TO CLIENTS Bed and Board Transportation Medication Management Case Management Coordination of Care Supportive Counseling Wellness Self Management

SERVICES PROVIDED TO CLIENTS (CONTINUATION) Advocacy and referrals 1. Entitlements 2. Medical 3. Mental Health 4. Substance Abuse

SERVICES PROVIDED TO CLIENTS (CONTINUATION) Activities of Daily Living 1. Budgeting 2. Time Management 3. Healthy Eating 4. Recreation

SERVICES PROVIDED TO CLIENTS (CONTINUATION) Housing 1. Eligibility 2. Application Process 3. Interviewing Skills 4. Apartment Seeking 5. Apartment Viewing 6. Moving Assistance

SERVICES PROVIDED TO CLIENTS (CONTINUATION) Family Reunification Vocational Counseling 1. Aptitude Assessment 2. Job Readiness Skill 3. Educational/Training

DISCHARGE FROM MEDICAL RESPITE PROGRAM Respite Coordinator will initiate discharge/transitional planning within 48 hours of the client s admission into the program. Staff activates screening procedures for food stamps, benefits (SSI) and employment assistance. Identify and arrange referral and placement in appropriate community based housing program or others.

Discharge from Medical Respite Program Coordinate and transport clients to appointments for housing interviews and appointments Arrange for transfer of client out of Respite to housing and assist with moving details; support the client to continue medical care.

LENGTH OF STAY IS DETERMINED BY THE FOLLOWING FACTORS: Severity of health condition Documentation of the severity of psychiatric condition Documentation of homelessness Severity of Substance abuse condition/history

LENGTH OF STAY IS DETERMINED BY THE FOLLOWING FACTORS: Patients without government identification. i.e. social security cards, birth certificates and/or those without legal immigration status contribute to longer lengths of stay.

CLIENTS DEMOGRAPHIC Ethnicity % of Clients (n= 52) African American 56% Hispanic 29% Caucasian 15%

CLIENTS DEMOGRAPHIC Gender Gender of Clients % of Clients (n=52) Male 81% Female 19%

AGE OF CLIENTS Age of Respite Clients Age % of Clients (n=52) Under 21 2% 21-35 31% 36-45 4% 46-55 27% 56-62 21% Over 62 15%

CLIENT INSURANCE Client Insurance Insurance % of Clients (n= 52) Medicaid 75% Medicare 5% Medicaid/Medicare 3% Medicaid-Mgt. care 8% No Insurance 9%

HOSPITAL ADMISSION INFORMATION Referring Hospital % of Clients Montefiore Hospital (n=37) 71% Bronx Lebanon Hospital (n=15) 29%

HOSPITAL ADMISSION INFORMATION (CONTINUATION) Reason for Admission to Hospital Reason for Admission % of Clients (n=52) Medical 65% Psychiatric 31% Substance 4%

HOSPITAL ADMISSION INFORMATION (CONTINUATION) Reason for Admission to Montefiore Hospital (n=37) Reason for Admission % of Clients Medical (37 Clients) 100% Psychiatric (0 Clients) 0% Reason for Admission to Bronx Lebanon Hospital (n=15) Medical (13 clients) 87% Psychiatric (2 clients) 13%

HOUSING STATUS PRIOR TO HOSPITAL ADMISSION Housing Status Before Admissions % of Clients (n= 52) Street Homeless 25% Shelter 4% Family/Friend 50% Apartment/rented Room 9% Nursing Home 6% Other (RV) 2%

HOSPITAL READMISSIONS Hospital Readmission Rate (n=52) Not Readmitted to Hospital (29 Clients) 56% Readmitted after Spending less than 30 days in Respite (14 Clients) Readmitted after spending more than 30 days in Respite (9 Clients) 27% 17%

CLIENTS READMITTED TO THE HOSPITAL (N=23) Hospital Readmission Less Than 30 Days In Respite (14 Clients) Reason for Readmission Medical Psychiatric Substance 86% 14% 0% Over 30 Days (9 Clients) 0% 100% 0%

EMERGENCY DEPARTMENT VISITS Emergency Department Visit Rates (n=52) No Visits to Emergency Department (42 Clients) Visited with less than 30 days in Respite (7 Clients) Visited with more than 30 days in respite (3 Clients) 81% 13% 6%

EMERGENCY DEPARTMENT VISITS Emergency Department Visit Rates (n=10) Visited with less than 30 days in Respite (7 Clients) Visited with more than 30 days in respite (3 Clients) Reason for Visit Medical Psychiatric Substance 100% 0% 0% 0% 67% 33%

PLACE OF RESIDENCE AFTER DISCHARGE FROM RESPITE PROGRAM (N=45) Type of Residence % of Clients Own Apt. (# of Clients 4) 9% Supportive Housing (# of clients 10) 23% Family/Friends (# of clients 14) 31% Hospital (# of clients 2) 4% Nursing/Adult Home (# of clients 9) 20% Shelter (# of Clients 3) 7% Rented Room (# of Clients 2) 4% Substance Abuse TX Long Term (# of Clients 1) 2% Current Respite Program Clients: 7 LENGTH OF STAY (AVERAGE 3 MONTHS)

Summary Prior to hospital admission, the majority of the clients lived with family/friends (50%) while 29 % were street homeless or lived in shelters. Sixty five percent (65%) of hospital admissions were for medical (non-psychiatric)reasons It is interesting to note that thirty one percent (31%) of the clients were discharged to family/friends from the Respite Program while 23% of the clients were discharged to supportive housing programs.

Summary Continued The majority of clients, 75%, were Medicaid recipients. Only 23% of clients were readmitted to the hospital for medical reasons after less than 30 days in the Respite program. The readmission rate seems to be lower than other Respite Programs. However, the re admission occurred early after the hospital discharge which is consistent with reports in the literature.

Summary Continued Only 13% of the clients visited the Emergency Departments within 30 days which is lower than reported in the literature. However, it occurred during the first 30 days in the Respite which is similar to other Respite Programs. 6% of the clients visited the Emergency Department for medical reasons after 30 days in the Respite program which is lower than the reports from other Respite Programs. Preliminary data shows that this Respite Program is effective and efficient in reducing cost to hospitals and Medicaid