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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 . Why should I care about research? How can I access info on health and homelessness?
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Respite CareResearch 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 • Why should I care about research? • How can I access info on health and homelessness? • Respite specific outcomes
Why care about Research? • Grant writing • Policy / Advocacy • Evidence Based Medicine • Quality Improvement
Quality Improvement resulting from Chicago Housing for Health Partnership • 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 • 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 • 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 • 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 • 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?
Respite Care Outcomes Project • 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) • 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 161 eligible and placed at Interfaith House Control Group 64 eligible, not placed due to lack of beds
Baseline – Age / Gender Respite Care Control P Value N=161 N=64 Age 43 44 0.54 ¹ Gender 0.59 ² Male 78% 81% Female 22% 19% ¹ T-test ² Pearson Chi-Square
Baseline – Race Respite Care Control P Value N=161 N=64 Race 0.05 ¹ AA 75% 67% White/Other 19% 16% Latino 6% 16% Other 1% 2% ¹ Pearson Chi-Square
Baseline – Diagnosis Respite Care Control P Value N=161 N=64 Diagnosis 0.07 ¹ Trauma 40% 23% HIV 27% 28% Infection 12% 14% Other 21% 34% ¹ Pearson Chi-Square
Prior 6 Month - Resource Use Respite Care Control P Value¹ N=161 N=65 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
Results - Bureau Resource Use during year following referral P=0.002 NS NS Model controlled for Age, Gender, Race, Diagnosis, Prior use
Effect of Respite CareHealth Utilization during year following referral - Controlling for Age, Gender, Race, Prior Utilization, Diagnosis
Effect on Inpatient use by Diagnosis I N P A T I E N T D A Y S P = 0.01 HIV InfectionTrauma Other
Respite Care Costs • 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 • Respite Cost per hospital day avoided: $706 • Costs of a hospital day • AHRQ estimate: $1500 per day • Most are uninsured
Respite Care Outcomes Patients receiving respite care: • 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 1University of Alabama at Birmingham ● 2Boston University/ Boston Medical Center ● 3Boston 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
Study Sample • 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
Discharged to Own Care (n=433) Respite Unit (n=136) Hospitalized Homeless 7/98-6/01 (n=784) Time to Readmission or Death Other Planned Care (n=174) Left AMA (n=41) Definition of Comparison Groups
Data Sources • Hospital Information System provided: • Inpatient discharge abstracts • Outpatient diagnoses, readmissions • Boston Health Care for the Homeless Program Databases • 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
Conclusions • Homeless patients placed in respite care had a 50% reduced odds of early readmission or death at 90 days • Other care environments (nursing homes) were not associated with a similar benefit • Inpatient days & charges also for respite program up to 90 days. • Effects diminished over time (persistent trend).
Reduction in Hospitalizations • 50-58% Respite Care • 35% Ace-Inhibitors for Congestive Heart Failure1 • 27% Carvedilol (β-Blocker) - Congestive Heart Failure2 1JAMA. 1995 May 10;273(18):1450-6. 2 N Engl J Med. 1996 May 23;334(21):1349-55.
Research - Next Steps • Health improvement • Mortality reduction • Detailed Cost analyses • Randomized trials
Conclusions • 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)