Too Healthy for the Hospital, Too Sick for the Streets

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: If you’ve ever been discharged from a hospital, you know the drill. 

You’re likely to get sent home with a pile of instructions — take these pills twice a day, stay off your feet, change your bandage. 

But what if you didn’t have a home to go back to?

For homeless people, even such simple tasks can be impossible.

On the street, their health deteriorates, they go back to the hospital, and the cost of their care climbs.

Karyn Wills: We’ve had people who have had more than 60 emergency department visits over 2 to 3 months.

DG: There is an alternative, an option for people too healthy for the hospital but too sick to be without housing. 

It’s called medical respite.

It’s been around since the mid-80s, but in the last 5 years, the number of programs has nearly doubled.

Today on Tradeoffs, why medical respite is gaining steam and the evidence behind whether this approach works. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein.

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DG: Henry Jones felt like he was at the end of the line.

Henry Jones: There was no way out. No way out. That’s what I see. I prayed and was tired, but I couldn’t see no way out.

DG: It was the middle of June 1991, and the 42-year-old former maintenance engineer had been homeless in Washington D.C. for 11 years.

He’d spent most of those years on his feet — working construction, hauling trash, walking the city.

Those years took a toll.

HJ: I started to get sicker and sicker, my legs and stuff started giving out on me. I could feel my health failing and I didn’t have the energy or nothing like that.

DG: On that hot June morning, Henry’s legs ached. His stomach hurt, his arms trembled.

He leaned on a lamp post 30 yards from the hospital. 

HJ: I could hardly move. My legs were hurting so bad.

DG: Henry stood there in the sun for half an hour before a security guard offered to drive him to the emergency room.

He waited eight hours to be seen.

When the medical team finally examined him, they told him there was nothing they could do.

HJ: They say you’re sick, but you’re not sick enough to stay here, and we’re not going to admit you.

DG: Henry just wanted someone to help him make the pain go away. 

That was proving nearly impossible as a homeless man in Washington D.C. in the summer of 1991.

But then, Henry  got lucky.

A hospital social worker referred him to a place called Christ House.

Janelle Goetcheus: To leave people like that on the street is, it’s wrong.

DG: That line says a whole lot about Dr. Janelle Goetcheus.

Janelle had run a primary care clinic for low-income and homeless people in northwest DC in the 1980s.

She knew some of her patients needed more.

JG: You can imagine if you’ve got an infected wound on your leg that’s getting larger, and we’re sending you right back on the street, it’s gonna get worse and worse. You begin to wonder, what are you doing? I mean, you’re just putting little tiny Band-Aids on what need to be done and you keep questioning, what more should I, could I be doing?

DG: Christ House was Janelle’s answer to her own question.

With help from a group of volunteers and a local philanthropist, she opened the home in 1985.

By the time Henry arrived, the place was admitting 300+ patients a year, it’s 34 beds in high demand.

HJ: I was shaking and trembling and I had a big old beard, and they had to put me in the wheelchair to roll me here.

DG: People came with broken bones, nasty cuts, frostbite — conditions you could usually heal from at home. 

On the street, any one of them, though, could be deadly.  

JG: It doesn’t take much to get that all back if you’re in the right setting and getting your medications and getting things checked on a regular basis.

DG: Nurses worked on-site 24 hours a day.

Physicians performed regular exams and made appointments with specialists.

A social worker helped men apply for health insurance, find housing and reconnect with family.

Henry had to blink to take it all in.

HJ: I couldn’t believe what I was seeing because I was sleeping in a clean, nice, clean bed. I was getting some good food to eat. The nurses and the doctors, they were so concerned. They just wanted me to get better, and I could see that.

DG: Janelle had transformed an abandoned apartment building into what we today call a medical respite facility — one of the nation’s very first.

Janelle converted the first floor into Christ House’s dining room and living room.

Bedrooms lined the hallway above. Some had two beds, others as many as eight.

HJ: You go upstairs, the second floor look like a baby hospital upstairs. It’s so clean and sparkling. 

DG: Doctors diagnosed Henry with diabetes, high blood pressure, heart problems and nerve damage in his legs.

Too high-functioning for the hospital, too sick for the streets.

HJ: If I had to went back to the shelter from here, I probably would have died on the streets. I know I would have. Yes.

DG: Instead, nurses helped Henry with his diet, gave him his medication and put him through physical therapy.

A year later, Henry’s case manager handed him the key to his own apartment.

DG: These days, more than 130 medical respite programs care for homeless people in 37 states and Washington D.C.  

They offer homeless people a place where they can recover from a surgery, learn to manage a chronic condition, and get help finding a permanent place to live.

These facilities are also unregulated, unlicensed, and look pretty much however they want.

Tiny homes in Nashville, an empty convent in Cleveland.

Julia Dobbins: We have a saying in our work that if you’ve seen one respite program, you’ve seen one medical respite program.

DG: That’s Julia Dobbins.

She’s the director of medical respite at the National Health Care for the Homeless Council.

The Council has been the main organization supporting — and studying — medical respite for the last two decades.

Julia says the most common setting for respite programs are homeless shelters — a few beds or a room set aside, daily check-ins with a nurse.

Others, like Christ House, offer kitchens, social spaces, exam rooms and round-the-clock medical care.

Whatever shape or size, Julia says they keep popping up.

JD: Medical respite, for lack of better words, is very in right now. 

DG: In the last five years, the number of respite homes has nearly doubled.

There are several reasons behind the interest in medical respite.

News clip: The number of Americans living without homes continues to rise at an alarming rate.

DG: Maybe the most obvious is this spike we’re seeing in the problem. 

News clip: In LA, homelessness has jumped 16% in a year.

DG: Federal officials estimate nearly 600,000 people were homeless in the U.S. in 2020.

That number has grown every year since 2016, all while the homeless population is getting older and sicker.

News clip: Northern Kentucky has seen a spike in older adults experiencing homelessness.

News clip: Nearly one-third of the homeless population in El Paso is classified as elderly.

DG: Research shows homeless people in their 50s are in worse health than folks in their 70s who have a place to live. 

And half of homeless adults are over 50.

But the growing interest in medical respite goes beyond numbers. 

We’ve seen a philosophical shift in recent years among doctors, health care executives, and state and federal policymakers. 

There’s broader agreement now that factors like housing impact people’s well-being and that health care should do something about it. 

Julia says enter medical respite, stage right. 

JD: It’s a lot easier today to start a respite program than it was 10 years ago. And there’s a lot of support to help communities get that up and running.

DG: Unlike when Christ House first opened its doors, there are now dozens of blueprints to follow.

Julia’s organization has adopted national respite standards.

And yes, the money has started to flow.

But it’s coming from a place you may not expect.

JD: Managed care organizations were coming to the table and saying, “Hey, we want to be able to access those programs. How can we be a part of this as well?”

DG: Managed care organizations. Those are private insurance companies hired by most states to run their Medicaid programs.

Historically, hospitals, philanthropies, and state and local governments have funded medical respite.

Now more insurers are focusing on the intersection of housing and health care.  

That, plus new financial incentives, have those insurers taking a hard look at medical respite.  

More on that when we come back.

MIDROLL

Jack Kline: But yeah, let’s walk around the house.

DG: Welcome back.

JK: Okay. So I’m going to introduce you to folks.

DG: On a rainy, mid-April morning in Washington D.C., Jack Kline walked our producer Ryan Levi around Hope Has a Home, one of a growing number of respite programs financed by insurance companies. 

They walked toward the back of a brightly painted ranch-style house, past an exam room and bedrooms with two hospital beds each.

JK: This is our kitchen. This is our little TV room. We run groups here during the day sometimes. 

DG: It was a quiet morning.

A resident in a green shirt and Notre Dame baseball cap watched a cooking show in the living room.

He shuffled to the kitchen counter where a nurse checked his blood sugar.

The man then warmed up a couple of frozen hot dogs for an early lunch.

Jack nods at the scene he’s helped create and run over the last three years. He says it’s a homey place. 

JK: We’ve set it up so that folks can feel at home. It’s a residence.

DG: Who would’ve thought that an insurance company would be behind a place like Hope Has A Home?

JK: The real push came from AmeriHealth Caritas, which is the largest provider of Medicaid managed care services to homeless adults in the District.

DG: In 2016, Washington’s Medicaid program started docking insurers’ pay if they failed to reduce hospital readmissions and unnecessary emergency room visits.

AmeriHealth estimated it provided Medicaid benefits to around 3,500 homeless people, and some of them used the hospital and ER a lot.

So the company ran the numbers and was persuaded medical respite could improve people’s health, help the business avoid financial penalties, and save up to $200,000 a year. 

The only problem? They needed some partners. 

That led AmeriHealth to Jack’s organization, a health and human services agency called Volunteers of America Chesapeake and Carolinas.

JK: We definitely wanted to be part of a mission to provide a new service for homeless adults.

DG: Jack’s group would run the facility.

A community health center would provide the medical care.

A local housing agency would try to connect residents with permanent housing.

And AmeriHealth would pay a daily rate for its patients to stay — enough money to fund the entire operation.

Two separate 8-bed facilities opened in 2019 and so far have served 62 homeless men.

About 1 in 3 respite programs now receive funding from Medicaid plans.

Why are insurance companies supporting this type of care for some of the most marginalized people in the U.S.?

Short answer: The Affordable Care Act.

Under the ACA, 38 states and Washington D.C. have expanded their Medicaid programs to include low-income adults with no children.

JD: So the number of folks on Medicaid skyrocketed.

DG: Julia Dobbins of the National Health Care for the Homeless Council says thousands of homeless people became eligible and have joined the ranks of the insured. 

As many state Medicaid programs pressure private insurers to cut expensive, avoidable care like hospital readmissions, more insurers are looking at medical respite as an answer. 

JD: Unfortunately, there’s not as much literature in the field as we wish there was.

DG: Julia’s team recently reviewed the existing research on medical respite.

She understands as this service becomes more popular with insurers, they want to know that it works.

JD: People want to invest in something that they feel very confident in. And we have a lot of anecdotal data about medical respite care, but people want to look at research.

DG: Much of the evidence has been self-published by medical respite programs.

No one has conducted a rigorous randomized control trial in the U.S.

Based on 20 peer-reviewed articles Julia says, three things seem clear. 

People who use medical respite spend less time in the hospital. 

They’re less likely to be readmitted to the hospital for the same thing.

And they’re more likely to use primary care.

Music to any insurance company’s ears.

And perhaps, even with the limited evidence, those findings explain why funding from Medicaid plans has shot up.

But will insurers save money? That is an open question.  

JD: There’s not enough literature out there about what exactly the cost savings or the return on investment are.

DG: With medical respite, sure, an insurer may avoid pricey hospitalizations.

It can also, though, extend someone’s life, some people who are super sick. 

Like with Henry Jones at Christ House back in ’91, medical respite could lead to the diagnosis of multiple chronic conditions and some really big bills. 

JD: We cannot underestimate how sick our folks are. And this is the first time, maybe in 10 years, they’ve really had a workup done and they’ve seen specialists. And maybe they have stage four lung cancer. And so their costs are going to shoot up after coming into a respite program.

DG: Case in point, AmeriHealth says the first 11 people they sent to Hope Has A Home went to the ER less.

But their primary care visits skyrocketed with total costs of care jumping 75%.

Now that’s just a small sample, and AmeriHealth remains committed with plans to launch two facilities for homeless women next year.

And other insurers getting into this understand the risks. 

KW: Everything that we do might not necessarily have a cost savings, and I don’t think that you go into health care looking to say everything that we have to do has to cut costs. It is important, but it’s not our primary driver.

DG: Dr. Karyn Wills is the chief medical officer for CareFirst, another Washington DC insurance company.

CareFirst just started sending people to respite last year.

Karyn hopes they’ll save money, but she’s realistic.  

KW: You’re dealing with a group of people that are so vulnerable, that many times, let’s be honest. Many times we drive down the street and you turn your eyes away from them. But each one of them are important. And so that’s why we’re that’s why we’re doing this.

DG: Most doctors and nurses dismissed or outright ignored Henry Jones over the 11 years he was homeless.

Then he landed at Christ House.

Henry still remembers what his roommate told him his first day back in 1991.

HJ: He was an old man. And he looked up at me and said, “Young man, this is the last stop to the graveyard. What you want to do with your life?” He was telling me that if I didn’t take advantage of what they would offer me on the second floor, if I went back out on the streets, I would have died.

DG: Today more people like Henry are going from the hospital to medical respite homes, and that trend looks like it’s only growing. 

Medicaid programs in Minnesota, Colorado, New York and Washington state are trying to expand access.

Utah has submitted a waiver to the federal Centers for Medicare and Medicaid Services, and California just had its waiver approved.

CMS is forbidden from paying for room and board, but these waivers show they’re open to this experiment.

Still, even if the feds got fully on board, we’re talking about helping a fraction of the nearly 600,000 homeless people nationwide.

JD: We are not going to end this crisis with medical respite beds alone. Medical respite care is not housing. 

DG: Julia Dobbins says some people, like Henry, find a permanent place to live after medical respite. 

But she says many end up back in the shelter or on the streets because there’s a lack of housing.

That forces respite homes to choose between releasing someone back to homelessness or keeping them in a bed that someone else needs.

JD: We have to always be talking about access to affordable housing. Or otherwise, we’re going to just keep talking about developing more and more respite programs. And while I’m here to support them, that is not my goal long term, for more and more and more respite programs and higher and higher numbers of people experiencing homelessness.

DG: I’m Dan Gorenstein, this is Tradeoffs.

This episode is part of a series on improving care for people with complex health and social care needs supported by the Better Care Playbook, an online resource for evidence-based practices and promising approaches to improve care for people with complex health and social needs.