Respite CareResearch Update

David Buchanan MDHead, Section of Social MedicineStroger 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 CityChicagoBoston

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 MDPablo 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 HospitalOct 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 ValueN=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

Baseline –Use of Bureau Resources6 Months Prior to Referral

0

1

2

3

4

5

6

Respite CareControl

Results - Bureau Resource Use during year following referral

0123456789

Respite CareControl

P=0.002

NS

NS

Model controlled for Age, Gender, Race, Diagnosis, Prior use

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

INPATIENT DAYS

-25

-20

-15

-10

-5

0

5

10

HIV Infection Trauma Other

P = 0.01

Respite Care Costs

Average respite costs: $3,476 / patient

Costs at Interfaith House: $79 / dayAverage respite days: 44Respite Cost per hospital day avoided: $706

Estimated Cost Savings

Respite Cost per hospital day avoided: $706

Costs of a hospital dayAHRQ estimate: $1500 per dayMost 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

Definition of Comparison Groups

Hospitalized Homeless 7/98-6/01

(n=784)

Hospitalized Homeless 7/98-6/01

(n=784)

Respite Unit (n=136)Respite Unit (n=136)

Discharged to Own Care (n=433)

Discharged to Own Care (n=433)

Other Planned Care (n=174)Other Planned Care (n=174)

Left AMA (n=41)Left AMA (n=41)

Time to Readmission or

Death

Time to Readmission or

Death

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

Unadjusted Results at 90 days

Characteristic RespiteOwn Care AMA

Other Care p

N 136 433 41 174

Readmission/Death 15% 19% 20% 22% .57

Inpatient Days 1.0 1.2 1.4 1.7 .35

Inpatient Charges $2522 $2819 $3722 $3910 .45

*At 90 days, deaths (N=7) were <5% of readmission/death outcomes (N=154).

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 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 webwww.nhchc.org

Salt Lake City paper / conference handouts for respite descriptions

Chicago & Boston Studies show ↓ hospitalizations50% reduction in next 90 days (Boston)58% reduction in next year (Chicago)