The need for more evidence

“Unfortunately, there’s not as much literature in the field as we wish there was,” Dobbins said.

Much of the evidence on medical respite has been self-published by medical respite programs, and no one has conducted a rigorous randomized controlled trial in the U.S.

There have been around 20 peer-reviewed articles, which Dobbins’ team reviewed for a recent literature review. That research strongly suggests people who use medical respite spend less time in the hospital, are less likely to be readmitted to the hospital, and are more likely to use primary care.

But there’s less evidence on whether medical respite is likely to save insurers money.

Paying a few hundred dollars a day to send someone to medical respite is certainly cheaper than paying thousands of dollars a night for them to stay in the hospital. But it can also extend someone’s life and uncover chronic conditions that will need years of management.

“We cannot underestimate how sick [homeless] folks are,” Dobbins said.

Case in point, AmeriHealth Caritas DC says the first 11 people they sent to Hope Has A Home went to the ER less. But their primary care visits skyrocketed, helping send total costs of care up 75%.

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

“Everything we do might not necessarily have a cost savings,” said Dr. Karyn Wills, chief medical officer for CareFirst, another Washington managed care organization that started paying for medical respite in 2021. “It is important, but it’s not our primary driver.”

Policy momentum and barriers

Policymakers in Washington state, Minnesota, Colorado and New York are exploring how they could expand access to medical respite through Medicaid. But a major roadblock remains.

The federal Centers for Medicare and Medicaid Services (CMS) is forbidden from paying for “room and board,” which has prevented medical respite from being covered by Medicaid the same as other services like a doctor’s visit or nursing home stay.

Managed care organizations have to set up individual contracts with each medical respite provider, and the money they spend on respite does not get factored into their annual contract negotiations with state Medicaid programs to determine how much state and federal money they receive.

In 2022, California became the first state to get a waiver from CMS allowing medical respite to be a covered benefit. Utah is in the process of getting its own waiver, more evidence that CMS is open to this experiment.

Respite providers, insurance companies, advocates and policymakers agreed that a bigger shift in CMS’ policy could open the floodgates to more medical respite. But even if that happened, it would still likely only touch a fraction of the nearly 600,000 homeless people in the country.

“We are not going to end this crisis with medical respite beds alone,” said Julia Dobbins. “Medical respite care is not housing.”

Forty percent of Christ House residents over the last three years have been discharged to a shelter or back on the streets. A similar share at Hope Has a Home also left without finding a stable place to live.

The lack of affordable housing forces respite homes to choose between releasing someone back to homelessness or keeping them in a bed that someone else needs.

“We have to always be talking about access to affordable housing for folks experiencing homelessness,” Dobbins said. “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.”

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.

The Better Care Playbook is coordinated by the Center for Health Care Strategies and made possible by Arnold Ventures, The Commonwealth Fund, The John A. Hartford Foundation, the Milbank Memorial Fund, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation and The SCAN Foundation.