Evaluation of Healthcare Evaluation of Healthcare for the Homeless for the Homeless
Program Impact on Program Impact on Emergency Room VisitsEmergency Room Visits
NJPCA Region II ConferenceJune 3, 2010
Stephane Howze, MPHVice President, Healthcare
DivisionHarlem United
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• ER utilization has increased sharply nationwide (31% increase from 1995 to 2005).[1]
• Homeless individuals account for a high portion of ER use; they are three times more likely than the general population to use the emergency department and tend to visit the ER repeatedly.[2]-[3]
• Roughly 26% of New York City (NYC) populations live at or below 200% of the federal poverty line, with poverty rates being much higher in East and Central Harlem.[4]
• Homeless individuals often have limited access to healthcare/primary care, have poor health status, and high rates of co-morbidities due to multiple barriers to quality healthcare
BackgroundBackgroundBackgroundBackground
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Harlem United’s Response
• Integrated care Model - offer medical care that is truly integrated with other essential services in a culturally competent, supportive, healthy healing community that meets clients’ multiple needs
• A “one-stop-shop” approach - allows members to benefit from a wide array of services in areas of medical and dental care, Mental Health services, expressive therapies, and case management.
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Harlem United – Who We AreHarlem United – Who We Are
COBRA Case Management
Assessment, Intensive Case Management,
Advocacy, Crisis Intervention
Supportive Housing Programs
Case Management, Primary Care Support, Treatment Education, Mental Health Services, Substance Use Counseling, Advocacy, Structured Socialization
Mental Health Services
Crisis Intervention, Individual and Group
Psychotherapy, Medication
Management, Expressive Therapies
Testing Services♦Rapid HIV testing ♦Innovative
recruitment strategies ♦Evaluation of testing strategies ♦Connection to primary care services ♦Access to HIV care through ADAP enrollment ♦ Uptown Health Link
Education and Training♦HIV Education and Community
Awareness events ♦African Immigrants Services ♦Black Men’s Initiative
Delivery of CDC-sponsored effective behavioral interventions ♦Healthy
Relationships ♦Many Men, Many Voices ♦Youth Space
Evening Food & Nutrition
Nutritional Assessment and Support, Treatment
Education, Psycho-Social Support
Women’s Housing (Scatter-Site)
Transitional Housing (Scatter-Site)
Permanent Congregate Housing
Prevention Prevention ServicesServices
Federally Federally Qualified Health Qualified Health Center & Related Center & Related
ServicesServices
Supportive Supportive HousingHousing Programs Programs
Adult Day Health Center East
Fully Bilingual (Spanish/English) Case Management, Treatment
Education, Support Groups, Harm Reduction Counseling, Auricular
Acupuncture, Primary Care Support
Adult Day Health Center West
Medical Care, Adherence Support, Nutrition
Counseling, Substance Use
Counseling, Structured Socialization, Pastoral
Care, Expanded Syringe Access Program
HUD Housing (Scatter-Site)
HRA Housing (Scatter-Site)
Dental Clinic
Primary Care
(Westside & Eastside)
Emergency Congregate Housing(Foundation House North & South)
FROST’D @ Harlem United♦Injection Drug User Care ♦Harm
Reduction ♦Syringe Exchange ♦Testing and Linkage to Healthcare
Healthcare for the Homeless
Healthcare & related services for the homeless
in Central & East Harlem
Vocational Education Program
The Blocks Project•Innovative prevention initiative
• Targets neighborhoods with high HIV prevalence, not high-risk sub-groups
•HIV education, testing and connection to care
•Additional social services via partners
Building Bridges Mental Health Program
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Harlem United - What We DoHarlem United - What We Do
• Founded at height of first phase of AIDS epidemic: 1988.
• In the early development, Harlem United (HU) specifically served people living with HIV/AIDS (PLWH/As) who were homeless and/or suffering from mental illness and/or substance use.
• Agency of last resort for medically-underserved communities of color in Harlem.
• Part of community-based movement to care for PLWH/As:Founded to address lack of response from established providers; Responding to the unique personal, social, and institutional barriers to care in Harlem.
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Harlem United – Healthcare Division
ADHCArticle 28License
1997
PrimaryCare
Amendment to
Article 28License
2000
Dental Amendment
to Article 28License
2003
El FaroExtension
Clinic OpenADHC & PC
2006
FQHC DesignationHomeless
2007
HIV FOCUSED
CENTER OF EXCELLENCE
MANAGING CHRONIC ILLNESS
2012Psychological
ServicesAmendment to
Article 28 License
2009
ALL VULNERABLE PATIENTS WITH A MULTIPLICITY OF NEEDS
ALL VULNERABLE PATIENTS WITH A MULTIPLICITY OF NEEDS
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Harlem United – Healthcare & Related Services
Community Case Management
Assessment, Intensive Case Management, Advocacy,
Crisis Intervention; VidaCare Case Management; Maintenance in Care
Wellness CenterMental Health and
Substance Use Services
Crisis Intervention, Individual and Group Psychotherapy, Medication Management,
Expressive Therapies
Evening Food & Nutrition
Nutritional Assessment and Support, Treatment Skills-
based Education, Psycho-Social Support and
Harm Reduction
HealthcareHealthcare& Related & Related ServicesServices
Adult Day Health Center East
Fully Bilingual (Spanish/English) Case Management, Treatment
Education, Support Groups, Harm Reduction Counseling,
Auricular Acupuncture, Primary Care Support
Adult Day Health Center West
Medical Care, Adherence Support, Nutrition Counseling,
Substance Use Counseling, Structured Socialization,
Pastoral Care
Primary Care
Dental Clinic
Federally Qualified Healthcare Center
Healthcare services for the Homeless in Central and East Harlem
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FQHC – Healthcare for the Homeless (HCH)FQHC – Healthcare for the Homeless (HCH)
• The FQHC-H designation allowed us to expand services to homeless people in Central and East Harlem communities who are predominantly African American and Latino(a) adults, and have histories of substance use and/or mental illness.
• This shift is very much aligned with our original mission; both our traditional clients and our new homeless clients are primarily poor, Africa American and Latino(a) adults, have histories of substance use and/or mental illness. All have experienced problems accessing medical care and supportive services.
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HCH Services – An Integrated Care ModelHCH Services – An Integrated Care Model
Primary Care clinic (Westside & Eastside)
GYN, Health Education, Directly Observed Therapy,
Psychiatry services, Preventive Health
Services, Management Of Chronic Conditions
Dental Clinic
- Diagnostic X-rays and Exams - Preventive Care- Emergency Care - Restorations-Endodontics -Prosthodontics-Periodontics - Oral Surgery- Referral to outside specialists for complex Surgical Procedures
Mental Health and Substance Use Services
Crisis Intervention, Individual And Group Psychotherapy, Medication Management, Expressive Therapies
Other services
Referrals, Outreach, and Case Management.
Federally Federally Qualified Qualified
Health CenterHealth Center
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HCH GoalsHCH Goals
• To increase access and eliminate barriers to care for homeless individuals in Central and East Harlem neighborhoods
• To improve health outcomes of homeless individuals
• To triage homeless individuals in Central and East Harlem neighborhoods from Emergency Room to our FQHC through HCH program
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Evaluating HCH EfficacyEvaluating HCH Efficacy
An outcome study was conducted in 2009 to evaluate An outcome study was conducted in 2009 to evaluate HCH efficacyHCH efficacy
Study QuestionStudy Question: Are there differences in frequency : Are there differences in frequency of ER visits among homeless clients who have been of ER visits among homeless clients who have been receiving HCH services and those who are new to receiving HCH services and those who are new to HCH?HCH?
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MethodMethod
Study Design: Cross-sectional study
Outcome variable: Frequency of ER visits
Sample- Baseline group: new HCH clients who had their first intake between January 1 – December 31, 2009- Follow up group: clients who have been receiving services provided by HCH, indicated by having at least two HCH visits between January 1 – December 31, 2009.
AnalysisT-test to determine whether or not there are any differences in frequency of ER visits among clients in baseline and follow-up groups
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Results – Demographics distributionResults – Demographics distribution
Both groups have similar demographics distribution
Age distribution
14%
0% 0%
29%
45%
8%9%
38%
48%
6%
0%5%
10%15%20%25%30%35%40%45%50%
<26 26-39 40-54 55-69 >70
Age group
% o
f cl
ien
ts
Baseline
Follow-up
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HCH: Diagnostic Distribution HCH: Diagnostic Distribution Results – Diagnosis distributionResults – Diagnosis distribution
Both groups have similar chronic illness distribution
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Results – FrequencyResults – Frequency of ER visitsof ER visits
Despite the similar demographics and chronic illness distributions, we observed a significant difference in the number of ER visits among the baseline and follow up groups.
Frequency of ER Visits in baseline and follow up groups
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Baseline Follow up
Groups
Ave
rag
e n
um
ber
of
ER
vis
its
per
per
son
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Results – Frequency of ER visitsResults – Frequency of ER visits
The difference in frequency of ER Visits among the baseline and follow-up groups could be attributed to comprehensive HCH interventions, as evident in the following findings:
Distribution of services received among clients in the follow up group
100%
33% 30%0%
20%
40%
60%
80%
100%
120%
PC Dental Other services
Types of services
Perc
enta
ge of
clien
ts
•100% of clients in the follow up group are engaged in Primary Care (PC)
• 33% are also engaged in Dental
•30% are engaged in other types of services, such as COBRA Case Management, ADHC, Maintenance in Care, and Mental Health
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Results – Frequency of ER visitsResults – Frequency of ER visits
• Clients in the follow-up group have an average of three follow-up visits in 2009. The visit types range from:
- PC follow-up- psychiatric visits- walk-in to get sick care- psychotherapy visits- etc
• Many of those visits would have been made to the Emergency Room had they not been engaged in HCH.
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Conclusions Conclusions
• Despite the absence of longitudinal analysis, findings may be regarded as preliminary evidence of HCH efficacy in triaging homeless patients from ER to HCH
• The convenience of our integrated care model, the culturally appropriate safe atmosphere that we create and the way we treat clients with dignity and respect are what made the homeless population, despite their transient nature, come back to seek care and comfort in our clinic instead of utilizing the expensive Emergency Room.