Henry Jones felt like he was at his wit’s end in the summer of 1991.
“There was no way out,” he remembers thinking. “I prayed and I was tired, but I saw no way out.”
Jones had been homeless in Washington, DC for 11 years, and the years had taken their toll. “I started getting sicker and sicker,” he said. “I could feel my health failing.”
On a hot June morning, Jones was in particularly bad shape – his legs ached, his stomach ached and his arms were shaking. A security guard had to drive him from the hospital parking lot to the emergency room because he could barely stand.
The hospital wouldn’t admit him, but a social worker referred him to a place called Christ House, a facility for homeless men who were too sick to be on the streets or in a shelter, but not sick enough to require hospital care. .
Today, there are a growing number of programs like Christ House that provide short-term medical care to homeless people, known as medical respite or recuperative care. The growth is fueled in part by a push for state Medicaid programs to provide support for patients to avoid avoidable health care use, such as emergency room visits.
“We saw more and more sick homeless people who were on the streets,” said Dr. Janelle Goetcheus, who opened the 34-bed facility in 1985. “So we just wanted to have a place where they could come and be cared for.”
By the time Henry Jones arrived in 1991, Christ House was admitting over 300 people a year.
“I couldn’t believe what I was seeing,” Jones said, recalling his first day. “I slept in a nice clean bed. I had good food to eat. The nurses and the doctors, they were so worried. They just wanted me to get better, and I could see that.”
Medical respite on the rise
Christ House was one of the first medical respite centers, and it is now one of 133 programs in 37 states and Washington D.C. They all provide homeless people with a safe place to recover from surgery or other acute illness, learn how to manage a chronic illness and get help finding permanent housing.
But the programs aren’t regulated or licensed, and they’re often incredibly different from one another, according to Julia Dobbins, director of medical respite at the National Health Care for the Homeless Council.
The most common setting is a homeless shelter – a few beds or a dedicated room with a nurse checking in once a day. Others, like Christ House, have their own building and include full-service kitchens, social areas, exam rooms, and 24-hour medical care.
Over the past seven years, the number of medical care homes has more than doubled, due to multiple factors.
First, the number of homeless people has increased every year from 2016 to 2020, reaching nearly 600,000. The homeless population is also aging and getting sicker. Research shows that homeless people in their 50s are in poorer health than people in their 70s who are housed, and half of homeless adults are over 50.
At the same time, physicians, health officials, and state and federal government policy makers have begun to accept that non-medical factors like housing impact people’s well-being and that the health sector health should do something about it, like medical respite.
Private Medicaid Plans Fuel Growth
Perhaps the most surprising driver of medical respite growth is interest from managed care organizations — the private insurance companies that cover 7 out of 10 people with Medicaid.
Most respite programs have multiple sources of funding. Hospitals, philanthropies, and state and local governments have always been the most common, but about 1 in 3 programs now receive funding from Medicaid plans.
Dobbins said it started when the Affordable Care Act allowed 38 states and Washington DC to extend Medicaid to low-income adults without children, bringing thousands of homeless people previously ineligible for Medicaid.
Many state Medicaid programs are simultaneously pressuring managed care organizations to reduce costly avoidable care, pushing more insurers to consider medical respite.
An example is AmeriHealth Caritas DC, one of three managed care plans in Washington D.C. In 2016, Washington’s Medicaid program began cutting insurers’ pay if they failed to reduce hospital readmissions and unnecessary emergency room visits.
AmeriHealth estimated that it provided Medicaid benefits to about 3,500 homeless people, and some of them were hospital and emergency room users a lot. The company analyzed the numbers and was convinced that medical respite could improve people’s health, help the company avoid financial penalties and save up to $200,000 a year.
From there, they partnered with other local organizations to launch Hope Has a Home, two new eight-bed medical care facilities that opened in 2019 and have so far served 62 homeless men.
“I thank God for this place,” said Wayne Gaddis, a 58-year-old who came to Hope Has a Home after undergoing spinal surgery. “If I wasn’t here I would have been on the streets, probably addicted again, slowly killing myself, not taking my meds, not caring because I feel like no one else is cared. But this place, it gives me new hope. New life.”
The need for more evidence
There have been about 20 peer-reviewed articles on medical respite, which Dobbins of the National Health Care for the Homeless Council and his team recently reviewed. This research strongly suggests that people who use medical respite spend less time in hospital, are less likely to be readmitted to hospital, and are more likely to use primary care.
But much of the existing evidence has been self-published by medical respite programs, and no one has conducted a rigorous randomized controlled trial in the United States.
“Unfortunately, there isn’t as much literature in the area as we would like,” Dobbins said.
And there’s even less evidence about whether medical respite is likely to save insurers money.
Paying a few hundred dollars a day to send someone for medical respite is certainly cheaper than paying thousands of dollars a night to have them stay in the hospital. But it can also prolong a person’s life and reveal chronic illnesses that will take years of treatment.
“We cannot underestimate how [homeless] people are,” Dobbins said.
For example, AmeriHealth Caritas DC says the first 11 people sent to Hope Has A Home went to the emergency room less. But their primary care visits skyrocketed, helping to drive up the total cost of care by 75%.
That’s just a small sample, and AmeriHealth remains committed to medical respite with plans to launch two facilities for homeless women next year.
“Not everything we do necessarily saves money,” said Dr. Karyn Wills, chief medical officer of CareFirst, another Washington-based managed care organization that began paying for medical respite in 2021. is important, but it’s not our main driver.”
Political dynamics and obstacles
Policymakers in Washington, Minnesota, Colorado and New York are considering how they could expand access to medical respite through Medicaid. But a major obstacle remains.
The federal Centers for Medicare and Medicaid Services are barred from paying for “room and board,” which has prevented medical respite from being covered by Medicaid on the same basis as other services like home visitation. a doctor or a stay in a retirement home.
Managed care organizations must establish individual contracts with each medical respite provider, and the money they spend on respite is not factored into their annual contract negotiations with state Medicaid programs to determine the amount of money they receive.
In 2022, California became the first state to obtain a CMS waiver allowing medical respite to be a covered benefit. Utah is in the process of obtaining its own waiver, further proof that CMS is open to this experiment.
Respite providers, insurance companies, advocates and policymakers agreed that a bigger change in CMS policy could open the floodgates for more medical respite. But even if that happened, it would likely affect only a fraction of the country’s estimated 600,000 homeless people.
“We are not going to end this crisis with medical respite beds alone,” said Julia Dobbins. “Respite medical care is not housing.”
Forty per cent of Christ House residents over the past three years have been sent back to shelter or returned to the streets. A similar share of Hope Has a Home also left without finding stable housing.
The lack of affordable housing is forcing respite homes to choose between sending someone back to homelessness or keeping them in a bed someone else needs.
“We always have to talk about access to affordable housing for homeless people,” Dobbins said. “Otherwise, we’re going to keep talking about developing more and more respite programs. And while I’m here to support them, that’s not my long-term goal.”
This story was produced by Compromisea podcast exploring our confusing, expensive, and often counter-intuitive healthcare system.