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.