Addressing Barriers to Housing and Health Care for the Chronically Homeless with State and Local Partnerships in New York City

The healthcare system is a point of frequent yet episodic contact for a subset of medically vulnerable, chronically homeless patients. Lack of communication between the healthcare system and community agencies contributes to poor social outcomes and early, excessive morbidity and mortality in this population. Two novel efforts in NYC partner the public hospital system with city and community homeless services providers. Program goals are to improve coordination between hospitals and community-based organizations, connect patients to consistent outpatient care and permanent supportive housing, and improve health and social outcomes while reducing healthcare expenditures. Hospital to Home, sponsored by the New York State Department of Health, employs an intensive care management and coordination model and links patients to primary care, supportive housing, and other needed services. Eligible patients are identified for enrollment using predictive modeling to identify patients at highest risk for frequent hospitalization. Measured outcomes include supportive housing provision and costs, health services use and costs, and patient reported health and social outcomes. The second program is a pilot focused on Chronic Public Inebriates who frequent the Emergency Department (ED). This pilot utilizes the point of contact with ED staff to link patients with providers of housing services in real-time, and also to evaluate and address potentially overlooked behavioral health needs. Patients are identified for inclusion based on frequency of prior alcohol-related ED visits and can be referred by community homeless services providers. Outcomes include feasibility of connection to services including supportive housing and impact on health care utilization.