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Respite Pilot Initiative

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					Respite Pilot Initiative
   Evaluation Results

          Academy Health
            June 2006
                      Suzanne Zerger
                    Research Specialist
       National Health Care for the Homeless Council
                 E-mail: szerger@nhchc.org
    BPHC Respite Pilot Initiative
   In 2000, $1 million available to support 6-
    10 respite pilot/demonstration programs.
   Eligibility: HCH grantees already
    supporting a respite program
   Goal: “to explore the viability of a variety of
    models of respite services”
Respite Pilot Initiative Grantees:
   Program Model Overview
Shelter-Based                       Care Facility
     Collaboration with local           Collaboration with care
      shelter for 24-hour beds –          facilities, which provide 24-
      usually separate from               hour caregiver staff,
      shelter population                  housekeeping, security,
     Health care providers visit         food
      respite patients daily             HCH program provides
     Shelter staff supervise             medical supervision,
      patients overnight with             including admission and
      medical services available          discharge oversight and
      on-call                             daily clinical visits
     CO, MO, WA                         FL, NY, ME, UT, OR
Respite Pilot Initiative Grantees:
Program Model Overview, cont.
Free-Standing                    Apartment
     HCH Program has                 Administrative needs
      control over both the            provided through
                                       collaboration and
      facility and the medical
                                       community
      care                             organizations
     CA                              HCH grantee provides
                                       medical supervision
                                      OH
       Categorizing Models
by Facility Type
  Apartment, Free-Standing, Shelter, Care
  Facility
Or
by Medical Services/Coverage
  clinician visiting a bed (in a shelter,
  apartment, etc.) vs. 24/7 medical coverage
  (care facility, free-standing)
       Respite Pilot Initiative
         Evaluation Aims
Goal:
“to evaluate the relative success of these differing
   models in achieving positive patient outcomes.”
Specific aims:
 To identify and document differing models of
   care for the delivery of respite services; and
 To assess the effect of respite services on the
   health of homeless people
          Evaluation Design
   Grassroots, Participatory
       read: the most labor and time-intensive
    approach possible
               Evaluation Methods
   Program-Level Data            Client-Level Data
       Program Survey                Database
            (pre/post)                    Submitted quarterly for
       Telephone interviews                consenting clients
            (pre/post)               Client Refusal Forms
                                      No-Admit Forms
                                      Anecdotal: success
                                       stories and ethical
                                       dilemmas
                  Finding
   All of these respite models are effective
    in caring for homeless persons who
    critically need health care. This
    evaluation has helped to articulate pros
    and cons associated with each, and will
    help communities develop programs
    that respond to their own needs and
    resources.
                  BENEFITS
   Resourceful (Shelter, Care)
    “These resources already exist in the
    community, so money goes toward the patients.”
   Exposure to others exiting homelessness (Care)
   Control over program conditions (Stand-alone)
   Allows families to stay together in privacy (Apt)
   Easy to win community backing (Apt)
   Link to broader systems of care (All)
               CHALLENGES
   Collaborating with Agencies - e.g. Conflicting
    missions/procedures, strict requirements, lack of
    control over discharge (Shelter, Care)
   Expensive (Stand-alone)
   Limits to complexity of need that can be met
    (Apt, Shelter)
   Location (Apt, Stand-alone)
   Growing need and shrinking resources (All)
              Referral Sources

61% - Hospitals
20% - HCH Clinics/Programs
10% - Non-HCH Clinics/Programs
8% - Other

(49% supplied medications)
           Referee Relations
  “Hospitals…are goal-oriented to get clients into
                        respite.”
Recommendations:
 Clear Criteria

 Education Efforts (“You cannot understate how
  much energy it takes to educate.”)
 Clinically-Coached

 Face-to-Face

 Maintain Malleability

                                  “Hospitals will lie…”
           Ethical Dilemmas
   What do you do when referrals don’t fit the
    program requirements, but there are no
    other community resources available for
    your patients?
   You have two (individuals) who are
    referred to the shelter with similar medical
    issues. You have one bed available. How
    do you decide who you will give the bed
    to?
             Finding


Respite clients have multiple, complex
health and psychosocial needs - and
long histories of homelessness.
        Client Characteristics
                      (N=1349)

   27% education beyond HS/GED
   63% became homeless in same city as respite
    program (74% in same state)
   43% homeless 1 year or more
   53% single/never married
   97% unaccompanied by family members
   15% veterans
   average 48 years old
   11% hispanic; 40% white; 32% african american
   88% from the U.S.
    Client Treatment History
Psychiatric problems – 33% (51%) (hospitalized
  for mental health – 16%
Alcohol problems – 42% (62%)
  in treatment for alcohol – 28%
Drug problems – 40% (56%)
  in treatment for drugs – 25%
Hospitalization
• 77% had been to an ER/ED in prior 30 days
• 60% had been hospitalized at least 1 days in
  prior 30 days
    Severity Ratings (OASIS)
0=Asymptomatic, no treatment needed at this time
1=Symptoms well controlled with current treatment
2=Symptoms controlled with difficulty – affecting
  daily functioning; patient needs ongoing
  monitoring
3=Symptoms poorly controlled, patient needs
  frequent adjustment in treatment and dose
  monitoring
4=Symptoms poorly controlled, history of
  rehospitalizations
    Top ICD-9 Code Categories
Primary Diagnosis (N=1507)
   Injury and Poisoning (21%)
   Diseases of the Skin and Subcutaneous Tissue (18%)
   Diseases of the Respiratory System (11%)
   Diseases of the Circulatory System (9%)
   Average Severity Rating: 3

Additional Admitting Diagnoses (N=2403)
   Mental Disorders (44%)
   Diseases of the Circulatory System (8%)
   Average Severity Rating: 2


New Diagnoses (N=342 for 14% of admissions)
   Average Severity Rating: 2
             Finding


For homeless persons able to receive
care in these respite programs, the
experience is unequivocally beneficial
to their overall health
Primary Diagnosis Severity
         Ratings
 50%
 45%                         Level 4
 40%                         Level 3
 35%
 30%                         Level 2
 25%
                             Level 1
 20%
 15%                         Level 0
 10%
  5%                         Unknown
  0%
       Admission Discharge
    Admission/Discharge Comparisons
                      (N=1507)

                     ADMISSION         DISCHARGE

Income Source

       None                      53%               44%
       Food Stamps               23%               32%


Regular Source of                34%               49%
Primary Care
Health Insurance –               53%               44%
None
             Housing Status
           Admission/Discharge
                        (N=1507)
                                   ADMISSION    DISCHARGE

Hospital                                 34%           8%
Shelter                                  23%          29%
Street/camp                              13%           4%
Doubled up                                11%          6%
Hotel/Motel                               4%           2%
Own house/apartment                       2%           5%
Transitional housing/program              1%           3%
Treatment program                         3%           6%
Other                                     5%           6%
Unknown                                   2%          32%
              Reason for Exit
Completed Treatment             41%

AWOL                            15%

Administrative Discharge        16%

Left Against Medical Advice     9%

Admitted to Hospital            8%

Other                           10%

Unknown                         2%
                      Finding


Much of the need for respite services
 remains unmet
 E.g. A preliminary review indicates some of the larger
 programs (e.g. WA, CO) are unable to admit half to two-
 thirds of the individuals referred to them.
      Summary of Findings
All of these respite models are effective
Respite clients have particularly complex
  combinations of problems and long
  histories of homelessness
For homeless persons able to receive care
  in respite programs - experience is
  beneficial to their overall health
Much of the need for respite svs remains
  unmet

				
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