243030 Addressing Barriers to Housing and Health Care for the Chronically Homeless with State and Local Partnerships in New York City

Monday, October 31, 2011: 8:50 AM

Maria Raven, MD, MPH, MSc , Department of Emergency Medicine, Health and Hospitals Corporation & NYU Medical Center, New York, NY
Ryan McCormack, MD, MPH, MSc , Emergency Medicine, NYU School of Medicine/Bellevue Hospital Center, New York, NY
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.

Learning Areas:
Administer health education strategies, interventions and programs
Chronic disease management and prevention
Conduct evaluation related to programs, research, and other areas of practice
Planning of health education strategies, interventions, and programs
Public health or related research
Social and behavioral sciences

Learning Objectives:
1. Define methods to improve outreach and engagement of the homeless population for inclusion in needed health and social services 2. Identify potential points for outreach and intervention in your own community 3. Describe methodology for reliably identifying high need, high-cost patients

Keywords: Homelessness, Access to Health Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the principal investigator and Project Director for a large, New York State Department of Health-sponsored Chronic Illness Demonstration Project focused on improving care and reducing costs for high cost frequent users of health services, many of whom are homeless or precariously housed
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.