Download Inpatient Days - National Health Care for the Homeless Council

Respite Care
Research Update
David Buchanan MD
Head, Section of Social Medicine
Stroger Hospital of Cook County
National Healthcare for the Homeless Conference
Portland, OR June 2006
Outline
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Why should I care about research?
How can I access info on health and homelessness?
Respite specific outcomes
Why care about Research?
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Grant writing
Policy / Advocacy
Evidence Based Medicine
Quality Improvement
Quality Improvement resulting from
Chicago Housing for Health Partnership
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Study of the Impact of Housing / Case Management
400 Chronically ill homeless people
Case Managers work together across agencies
Participants are in CHHP stay in CHHP
Reduced barriers to accessing housing
Exploration of harm reduction respite model
Shift toward harm reduction permanent housing
Outline
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Why should I care about research?
How can I access info on health and homelessness?
Respite specific outcomes
Summary - Homelessness and Health
 Very
sick
 Use a lot of services
 Die young
Accessing info - Health & Homelessness
Suzanne Zerger’s guides
at: www.nhchc.org
A Preliminary Review of Literature: Chronic
Medical Illness and Homeless Individuals
Learning about Homelessness & Health in
your Community: A Data Resource Guide
Developing Outcome Measures to Evaluate
HCH Services (61 pages) by Pat Post
Outline
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Why should I care about research?
How can I access info on health and homelessness?
Respite specific outcomes
 Salt Lake City
 Chicago
 Boston
Descriptive Study
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It Takes a Village: A Multidisciplinary Model for the
Acute Illness Aftercare of Individuals Experiencing
Homelessness
Gundlapalli, Hanks, Stevens, Geroso, Viavant, McCall,
Lang, Bovos, Branscomb, Ainsworth
Journal of Health Care for the Poor and Underserved,
Volume 16, Number 2, May 2005
Respite Care
Outcomes
Project
David Buchanan MD
Cook County Bureau of Health Services / Rush University
Bruce Doblin MD MPH
Interfaith House Medical Director
Theo Sai MD
Pablo Garcia MD
American Journal of Public Health, July 2006
Interfaith House / Chicago Outcomes
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Chicago’s primary respite care center
Average length of stay: 45 days
40% of clients from Cook County Hospital
Able to serve less than half of eligible referrals
Research Question
Does respite care affect client’s future use of:
Hospital days,
 Emergency Room visits,
 Clinic Services?
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Respite Care Outcomes Project
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Retrospective review of Cook County Bureau of
Health Services admin data
Subjects: All eligible clients referred for respite
Time Period: October ‘98 - December 2000
Outcome: County Service use during next yr
 Inpatient Days
 ER Visits
 Clinic Visits
Participants (N=225)
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78% Male
73% African-American
8% Latino
Diagnoses:
 35% Trauma
 28% HIV
 13% Infection
 24% Other
225 Referred by Cook
County Hospital
Oct 98 – Dec 2000
Respite Care Group
Control Group
161 eligible and placed at
Interfaith House
64 eligible, not placed due
to lack of beds
Baseline – Age / Gender
Respite Care
Age
Control
N=161
N=64
43
44
P Value
0.54 ¹
0.59 ²
Gender
Male
78%
81%
Female
22%
19%
¹ T-test
² Pearson Chi-Square
Baseline – Race
Respite Care
N=161
Control
P Value
N=64
0.05 ¹
Race
AA
75%
67%
White/Other
19%
16%
Latino
6%
16%
Other
1%
2%
¹ Pearson Chi-Square
Baseline – Diagnosis
Respite Care
N=161
Control
P Value
N=64
0.07 ¹
Diagnosis
Trauma
40%
23%
HIV
27%
28%
Infection
12%
14%
Other
21%
34%
¹ Pearson Chi-Square
Prior 6 Month - Resource Use
Respite Care
N=161
Control
N=65
P Value¹
Inpatient days
5.8, 2 (0, 8)
5.3, 0 (0, 7)
0.23
ED visits
1.5, 1 (0, 2)
0.9, 0 (0, 1)
0.02
Clinic visits
1.8, 0 (0, 2)
1.8, 0 (0, 1)
0.42
Note: numbers above are mean, median (25th, 75th percentile)
¹ Mann-Whitney
Baseline –Use of Bureau Resources
6 Months Prior to Referral
6
5
4
3
Respite Care
Control
2
1
0
c
en
ati
ini
Cl
ER
Inp
t
Results - Bureau Resource Use during
year following referral
P=0.002
9
8
7
6
5
4
3
2
1
0
NS
Respite Care
Control
NS
c
en
ati
ini
Cl
ER
Inp
Model controlled for
Age, Gender, Race,
Diagnosis, Prior use
t
Effect of Respite Care
Health Utilization during year following referral
Respite
Control
P Value
Inpatient Days
3.4
8.1
0.002
ER Visits
1.4
2.2
0.09
Clinic Visits
6.7
6.0
0.60
- Controlling for Age, Gender, Race, Prior Utilization, Diagnosis
Effect on Inpatient use by Diagnosis
10
I
N
P
A
T
I
E
N
T
D
A
Y
S
5
P = 0.01
0
-5
-10
-15
-20
-25
HIV
Infection
Trauma
Other
Respite Care Costs
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Average respite costs: $3,476 / patient
 Costs
at Interfaith House: $79 / day
 Average respite days: 44
 Respite Cost per hospital day avoided: $706
Estimated Cost Savings
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Respite Cost per hospital day avoided: $706
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Costs of a hospital day
 AHRQ estimate: $1500 per day
 Most are uninsured
Respite Care Outcomes
Patients receiving respite care:
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Needed 4.7 fewer Hospital Days (58% reduction)
Trend toward reduced ER visits (36% reduction)
Had similar clinic use
HIV patients had greatest reduction in hospital days
Overall cost savings exceed respite costs
Hospital Discharge to a
Homeless Medical Respite
Program Prevents Readmission
Stefan G. Kertesz, MD, MSc1 ● Michael A. Posner, MS2
James J. O’Connell, MD3 ● Ashley Compton, BS1
Stacy Swain, MPH3 ● Michael Shwartz, PhD2 ● Arlene S. Ash, PhD2
1
University of Alabama at Birmingham ● 2Boston University/ Boston Medical Center ●
3
Boston Health Care for the Homeless Program
Support: Boston Health Care for the Homeless Program (2001-02) Lister Hill Center
for Health Policy (2002-03)
Design
Subjects: Hospitalized homeless persons
 Groups: Post-hospital placement site
 1º Outcome: Re-admission / death - 90 days
 2º Outcomes: Inpatient days & Hospital charges
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Study Sample
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Retrospective study, administrative data
People who got into the study had…
 Experienced a non-maternity medical/surgical
hospitalization between 7/1/98-6/30/01
 used an outpatient homeless health program
People were excluded for…
 duplicate or unfound records
 index admission for childbirth
 died during index admission
 re-hospitalized within one day
Definition of Comparison Groups
Discharged to Own Care
(n=433)
Hospitalized
Homeless 7/98-6/01
(n=784)
Respite Unit (n=136)
Other Planned Care (n=174)
Left AMA (n=41)
Time to
Readmission or
Death
Data Sources
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Hospital Information System provided:
 Inpatient discharge abstracts
 Outpatient diagnoses, readmissions
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Boston Health Care for the Homeless Program
Databases
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Massachusetts Registry of Vital Statistics
Adjustment for Potential Confounders
 Age,
Sex, Race-ethnicity
 Drug and Alcohol Abuse
 Index hospital length of stay
 Illness
burden, chart review of prior 6 months
Unadjusted Results at 90 days
Characteristic
Respite
Own
Care
N
136
433
41
174
15%
19%
20%
22%
.57
1.0
1.2
1.4
1.7
.35
$2522
$2819
$3722
$3910
.45
Readmission/Death
Inpatient Days
Inpatient Charges
AMA
Other
Care
*At 90 days, deaths (N=7) were <5% of readmission/death outcomes (N=154).
p
Multivariable-Adjusted Results at 90 Days
Variable
Odds Ratio (95% CI)
Respite
0.5 (0.3-0.9)
*Logistic Regression adjusted also for Age, Sex, Race/Ethnicity, & Drug Abuse
Conclusions
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Homeless patients placed in respite care had a 50% reduced odds
of early readmission or death at 90 days
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Other care environments (nursing homes) were not associated with
a similar benefit
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Inpatient days & charges also  for respite program up to 90 days.
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Effects diminished over time (persistent trend).
Reduction in Hospitalizations
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50-58% Respite Care
35% Ace-Inhibitors for Congestive Heart Failure1
27% Carvedilol (β-Blocker) - Congestive Heart Failure2
1JAMA.
2N
1995 May 10;273(18):1450-6.
Engl J Med. 1996 May 23;334(21):1349-55.
Research - Next Steps
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Health improvement
Mortality reduction
Detailed Cost analyses
Randomized trials
Conclusions
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Everything you need to write grants is on the web
 www.nhchc.org
Salt Lake City paper / conference handouts for respite
descriptions
Chicago & Boston Studies show ↓ hospitalizations
 50% reduction in next 90 days (Boston)
 58% reduction in next year (Chicago)