Dr. Maria Raven is an Assistant Professor in the Department of Emergency Medicine at the University of California, San Francisco. She completed her emergency medicine residency training and a CDC-funded Fellowship in Medicine and Public Health Research at Bellevue Hospital/New York University. While on faculty, she oversaw the implementation of NYC Health and Hospital Corporation’s State Department of Health-sponsored Chronic Illness Demonstration Project. At UCSF, Dr. Raven works clinically in the Emergency Department at Moffitt-Long, and conducts research related to emergency medicine payment policy and frequent users of the health system. She also works with the San Francisco Health Plan to assist with management of their highest cost members.
I recently co-authored a report published by the United Hospital Fund entitled Time and Again: Frequent Users of Emergency Department Services in New York City. We found that 11 percent of all emergency department users with two or more visits experienced at least one move between neighborhoods, and that moves increased with increased ED use in a given year. These moves are likely a marker for housing instability and homelessness. Recent literature has supported the idea that provision of supportive housing for heavy users of health care services who are homeless can result in decreased health care utilization and costs. As a result, policy makers and planners are beginning to realize that for at least some populations, solving homelessness could have an added benefit: bending the health care cost curve.
To date, separate and restricted funding streams have made the integration of housing and health care challenging.
- How can we make meaningful connections for patients, share data, and integrate services across siloed systems of care?
- When someone is discharged from the ED or the hospital and that person is homeless, whose obligation is it to assure continuity of care, which can include efforts towards housing placement or services provision within supportive housing or shelter?
- How can providers outside of the healthcare system obtain real-time information about what occurred in the hospital given strict patient privacy laws?
These are questions that must be addressed. CSH understands this, and is helping to lead the effort to better integrate state Medicaid programs and housing.
In New York City, I recently oversaw one of six State Department of Health sponsored Chronic Illness Demonstration Projects (CIDPs) designed to improve care and reduce costs for high risk, high cost Medicaid beneficiaries. Based on pilot work, we understood that a significant percentage of our enrollees would be homeless or precariously housed. We addressed this issue by employing a full time Housing Coordinator who thoroughly understood both the health care system and the housing system in New York and worked within both settings. We established data sharing agreements that allowed for information exchange between the public hospital system and multiple homeless services agencies, and our program staff followed patients across systems of care, from the emergency department or hospital to the shelter, street, or supportive housing unit. By providing accountability across the entire spectrum of care, and enabling our staff to work across silos, we have been able to show that over time we can decrease health care costs while increasing connections to outpatient care. For the patients in our program that were homeless, we hit severe roadblocks during program implementation that hindered our ability to rapidly house eligible enrollees: Section 8 vouchers were abolished, work advantage vouchers (New York City's pilot short-term homeless rental assistance) were rescinded, and there was little to no housing stock. But for those we housed---and I firmly believe that through our advocacy, more of our enrollees were housed more quickly that they would have been without our services---we witnessed notable reductions in hospital days and ED visits by the end of the first year.
Most recently, New York State submitted an application for a Medicaid waiver from the federal government, which includes a Medicaid Supportive Housing Expansion program that will dedicate $150 million annually to expand access to supportive housing. Researchers, providers, and advocacy organizations must continue to highlight the social, health, and fiscal benefits of these connections so that innovative proposals such as these will continue to support federal, state, and local efforts to bridge the worlds of housing and health.