BY DARCY LEWIS

Consider this scenario: You’re a physician working in the emergency room (ER) of a hospital. You have a patient who has shown up in your ER 30 times in just one year; 15 of those visits ended up in hospitalization. Despite effective treatment at each visit, your patient continues to be sick. To help stabilize this patient’s health, perhaps you write a prescription, suggest follow-up care through a primary care physician or outline a change in diet or exercise.

Living unhoused increases the risk for infectious and non-infectious disease.

Centers for Disease Control and Prevention.

Photo courtesy of Shutterstock

Now let’s complicate the story a bit: Your patient is unhoused or lacks consistent housing, which means when they are discharged from the hospital, their health may continue to be at risk. Perhaps your patient has a substance use disorder or a mental-health condition, or both. These conditions can potentially complicate your patient’s ability to fill a prescription, find follow-up care and make other lifestyle changes that could promote better health.

In short, your patient has complex needs far beyond what an ER visit—and hospitalization—can meet. How do you offer truly effective care that addresses all the conditions affecting this person’s health?

If you’re Randy Jotte, MD, Washington University emergency medicine specialist at Barnes-Jewish Hospital, you can evaluate your patient for eligibility to participate in a new program called Hospital to Housing.

At its inception, Hospital to Housing was a joint project supported by Barnes-Jewish Hospital, BJC HealthCare and St. Louis social services agency St. Patrick Center. The program employs a long-range, multi-pronged approach designed to help people with complex, interrelated needs find housing and achieve better health.

Jonathan Belcher, MSW, a senior director at St. Patrick Center, says, “Our goal with Hospital to Housing is to help people become stabilized, then connect them to community and behavioral health services and, ultimately, assist them to secure permanent housing.”

From hospitalization to home

The first step in the program begins with Jotte, medical director of the Hospital to Housing program. He regularly reviews patient charts in the electronic medical record, looking for people with an excessive number of ER visits. “I identify people with at least six visits in six months, but we have patients who have visited dozens of times within that same timeframe,” he says. Some of these visits do require hospitalization; others could be better managed through a primary care physician rather than in an emergency room. By identifying and working to reduce ER visits, Jotte can help ensure that frequent visitors receive the care they truly need. At the same time, he’s conserving the resources of the emergency department team, ensuring they have the capacity to treat others arriving with acute medical needs.

To be eligible for the Hospital to Housing program, an identified person must be unhoused or housing insecure, meaning they do not have consistent, safe and reliable housing. They must also have substance use disorder or mental illness. In describing potential candidates for the program, Jotte uses the analogy of a five-card hand of poker. “We care for folks who have been dealt three or four bad cards, through no fault of their own, including schizophrenia, early parental abuse or abandonment and cognitive challenges,” he says. “They’ve been adrift in the health-care system.”

Jotte reviews the reasons for each potential candidate’s ER visits and determines ways these visits could be handled more effectively and efficiently. For example, a person with diagnosed angina or seizure disorder may be exhibiting symptoms because they have run out of the medication that manages their symptoms.

Living unhoused increases the risk for developing mental illness, including anxiety, depression and post-traumatic stress disorder.

Centers for Disease Control and Prevention.

Photo courtesy of Shutterstock

In such cases, the best response may be a renewed prescription rather than a full work-up. “And if the police bring in someone with schizophrenia for being combative, we can work with a psychiatrist to perhaps determine that this person’s behavior has changed because they are due for another dose of their long-acting, injectable drug,” Jotte says.

Once Jotte identifies a patient’s eligibility for the Hospital to Housing program, a hospital-based social worker familiar with the patient’s history will receive a text the next time that patient comes to the hospital. The social worker will meet the patient in the ER to discuss the program and, if the patient chooses to participate, will send the patient’s information to St. Patrick Center. A social worker from St. Patrick Center will then visit the patient to initiate enrollment in the program. The patient will receive needed medical care, as well as a schedule of additional follow-up appointments and transportation to them, as needed.

In most situations, the St. Patrick Center social worker will secure interim housing for a program candidate at the first meeting. “Once we have identified someone who needs assistance through Hospital to Housing, and we have a spot available, we can move them in immediately rather than having to wait for a landlord to conduct background and credit checks or make the unit ready,” Belcher says. “St. Patrick Center makes sure the unit is ready and available the same day, and is stocked with necessities, including food, furniture and supplies.”

Lack of transportation can be a contributing factor to poor health, says Jessica Craig, program manager of hospital programs at St. Patrick Center. “It’s hard to keep up with appointments when you’re unhoused. By offering housing and transportation, we’re helping people re-engage with their health care in positive and effective ways.”

As needed, St. Patrick Center social workers will help their Hospital to Housing clients with routine tasks such as obtaining prescription medications. “We may take clients to the pharmacy and offer skills training related to managing and picking up prescriptions,” Craig says. “Some of our clients haven’t had the opportunity to learn how to manage prescriptions.”

After housing is secured and basic medical and prescription needs are met, St. Patrick Center assists clients through intensive support services and training, including the development of personal goals. These services are designed to help the client over a three- to six-month period. Interim housing can last longer if needed, Belcher says, but the ultimate goal is to help each client find permanent housing.

Coaching in essential life skills is also part of the Hospital to Housing program. “Some of our clients have not been successful in maintaining traditional housing,” Craig says. “They may not know how to clean and maintain their home, nor how to store food safely.” In addition to helping clients with these skills, Craig says, “we also help them use diet to manage health conditions, and we can teach them how to choose healthy food if needed.”

A snapshot of success

From its pilot phase in 2019 to its current expansion phase, Hospital to Housing has helped more than 70 people. Jotte says that, in addition to carefully monitoring the clinical and social services arms of the program, Hospital to Housing staff pay close attention to the program’s financial health, a factor that has helped ensure its continuing success.

Living unhoused increases the risk of postponing health care, which can lead to serious illness and death.

Centers for Disease Control and Prevention.

Photo courtesy of Shutterstock

Because Hospital to Housing is a voluntary program, some people who are eligible have chosen not to participate. Tracking outcomes for these people, as well as program participants, has helped illustrate the program’s benefits. In a comparison of 30 participants and 28 non-participants over two years, the rate of ER visits for participants dropped by about 50%, from 33 visits in one year to 16 the next. For non-participants, the visit rate remained virtually unchanged: 30 visits one year, 28 the next.

Before joining the Hospital to Housing program, participants generated $19,700 in hospital costs per patient per year. After joining the program, that annual per-patient cost dropped to $7,200, for a savings of $12,500 per patient per year.

The program also shows impressive early retention rates. After one year, 80% of participants had secured independent housing, compared to 66% of those who declined to participate. To date, Hospital to Housing has been quite cost-effective. The average cost per client is $1,215 per month, including housing, food and case management.

The Foundation for Barnes-Jewish Hospital, through generous donors, provided funding for non-hospital expenses during the pilot stage of the program. Financial support from the Foundation has continued during the program’s current expansion phase.

Additionally, the program received $800,000 in federal funds from the Substance Abuse and Mental Health Service Administration (SAMHSA), with the award coming through the office of U.S. Congresswoman of Missouri Cori Bush. Bush, a registered nurse, has provided support because she recognizes the program’s potential to benefit vulnerable people, the community and the health-care system.

Looking beyond the stats

As impressive as the numbers are, the real value of Hospital to Housing can’t be counted in dollars or statistics. “It’s truly empowering to see somebody go from living unhoused and in crisis mode to being excited and happy,” Belcher says. “We see people wanting to work on their goals and wanting to work with psychiatry or substance use counselors to focus on the things that will keep them stabilized in the community.”

When asked to sum up how Hospital to Housing can affect people’s lives, Jotte recalls a patient who used St. Louis’ light-rail system as shelter and suffered frequent assaults there. “This person also had cardiomyopathy. With each visit to the ER and subsequent admission to the intensive care unit, we could see this condition was worsening,” he says. “But Hospital to Housing found an apartment and provided a motorized scooter. This patient’s condition stabilized with proper medication, and they lived at home, in peace and safety, before dying in their sleep six months later. How can you put a price on that?”