During the last week of January 2020, outreach workers and volunteers across the country conducted the bi-annual “point-in-time” count of the homeless population living in shelters and on the streets. This federally mandated tally will determine, in part, the funding that states receive to help combat homelessness. This effort is part of the McKinney-Vento Homeless Assistance Grants program, established and expanded during the Reagan and Bush eras. Despite nearly two decades of a Housing First philosophy, homelessness is a growing crisis that continues to overwhelm social safety nets. When the options run out and the harsh realities of life on the streets catch up, hospital emergency departments often may seem like the only place left for people experiencing homelessness to find help.
The United States has an increasingly aging homeless population, with the average age now approaching 50 years old. Compared to the housed population, these individuals are twice as likely to suffer from disabilities, and over half have at least one chronic medical condition. Food insecurity and lack of housing further complicates physical and mental health. Tragically, EDs have a revolving door of homeless patients that are too sick to be safely discharged to the streets or shelters, yet not “sick enough” to meet hospital admission criteria. Inevitably, poor living conditions prevent hope of recovery. Eventually their health worsens and necessitates hospital admission for a few nights. Upon discharge, access to doctors and social workers are limited. Navigating the system, even in good health, is daunting. Shelters decline medically complicated patients, skilled-nursing facilities have strict admission criteria and receiving housing under the Housing First model can take weeks to months, if not longer. An interim housing option is needed.
Medical Respite Programs offer a promising solution to provide higher quality healthcare at a fraction of what it is currently costing taxpayers. This unique type of shelter, also known as a recuperative care center, is specifically designed to care for the homeless sick as they recover and arrange for permanent housing. According to the National Health Care for the Homeless Council, there are 75 active centers across 29 states with an average of 21 beds at each facility. A dismally small number — compared to the demand for such services.
Homeless patients who are admitted to the hospital experience medically unnecessary discharge delays that may stretch out four or more days longer than those with homes to which to return. Lack of options for patients experiencing homelessness impedes the entire hospital system, as fewer available inpatient beds, in turn, decreases availability of Emergency Department exam rooms, resulting in more crowded waiting rooms. Upon eventual release from the hospital, the patient is back to the same predicament they were in prior, and nearly six times more likely to be readmitted to the emergency department within the subsequent 30-days.
Ending up back in the hospital can result from the near impossibility of situations like trying to recover from pneumonia or undergo chemotherapy while sleeping in unsheltered conditions. Even the “lucky” few who obtain a bed in a shelter must remain vigilant to avoid having medications and belongings stolen.
Medical respite care offers an alternative to this inhumane and ineffective cycle, yet woefully underfunded and under-recognized for the benefits to individuals and society provided. A Centers for Medicare and Medicaid Services (CMS) study found that a single Respite Center saved Medicaid and Medicare nearly $5 million per year! A study out of Cook County found that in the 12-months following a stay at a respite center, individuals had 50% fewer hospital admissions.
Respite care has been modeled repeatedly since the 1980’s with overwhelmingly positive results. Consider the example of Circle the City, a 501(c)(3) nonprofit organization that has been providing respite care for the homeless in Maricopa County, Arizona, since 2012. Through private, federal and state funding, Circle the City offers integrated health care and social services at two 50-bed locations. By operating as a Federally Qualified Health Center they are able to participate in a shared savings program with two managed care organizations and to negotiate a Prospective Payment System with the state Medicaid agency, Arizona Health Care and Cost Containment System. Since 2017, they have annually been awarded a portion of the McKinney-Vento Homeless Assistance Grant distribution from the U.S. Department of Health and Human Services Health Resources and Services Administration. Most importantly, they have fostered countless community relationships with local business, hospitals to provide and advocate for this vulnerable population. Despite this, they continue to rely on private donations for most of their funding. All of this allows for the care of more than 9,000 people every year, 70% of whom leave the respite center into permanent housing – putting an end to the cycle of chronic homelessness. Circle the City and numerous other respite centers provide a solid framework to create successful systems of care for the homeless throughout the country.
Providing health care to the homeless is an issue that affects everyone. It is time that we, and our elected officials, embrace the solutions at hand. Respite Centers are a critical component of the health care system, and a vital resource in the pursuit to end homelessness. Respite programs must be expanded as a bridge to other services, like vital Housing First initiatives. They can no longer be supported by private donors alone; local and national policy makers, city and hospital officials, need to become more actively involved to promote humane and efficacious strategies to assist these highly vulnerable members of our society.
Amy Capone is a fourth year MD/MPH student at the University of Arizona College of Medicine – Phoenix studying to be an Emergency Medicine physician.
Jen Hartmark-Hill, MD, FAAFP is a Mayo Clinic trained Family Medicine physician who has served as the medical director for Street Medicine Phoenix. She is an Associate Professor in the Department of Bioethics and Medical Humanism at the University of Arizona College of Medicine-Phoenix and Chair of the Public Health Committee for the Arizona Medical Association.