Sick and homeless: Seattle takes big step to intervene

Medical respite care can reduce costs from ER visits in the weeks after a health crisis. And it can also wind up helping homeless people back into housing.

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Jefferson Terrace

Medical respite care can reduce costs from ER visits in the weeks after a health crisis. And it can also wind up helping homeless people back into housing.

Last week, a car struck you as you crossed University Way. You were taken to UW Medical Center, where you spent several days being treated for lacerations, a severely sprained knee, a broken rib, a concussion, and a bad case of nerves. Excellent medical care has helped you heal enough to be sent home with instructions to relax, rest, and keep your stitches clean.

Trouble is, you’re homeless.

In such a situation, it's easy for medical troubles to compound themselves rapidly. Trying to care for oneself, deal with pain, and avoid infection or other complications can all prove especially challenging for a homeless individual. A wound can become infected or stress can lead to cardiovascular problems. A person living under an overpass may soon be back in the emergency room trapped in the costly cycle of ambulance rides, medical tests, hospital stays, and discharges into the mean streets of the city.

Seattle has long been a recognized leader in medical respite programs, with 22 respite beds located in two of the city's homeless shelters, and recently took a major step to help close this costly revolving door of emergency services. This month, a third program opened at Jefferson Terrace, a high-rise apartment building owned and run by Seattle Housing Authority (SHA) for low-income residents, with Harborview Medical Center as the program's care provider. The new center, which is close to three major hospitals, has 34 beds that will serve about 500 patients per year from King County hospitals during stays averaging three weeks, more than doubling the county's medical respite capacity.

Medical respite programs serve homeless people who are well enough to be discharged from hospitals and are mobile, but who are still too sick to stay in shelters. They are assured a bed and follow-up medical care. In 2010 there were about 52 respite programs in the U.S. Many were established in California after a Los Angeles scandal several years ago prompted the passage of a law prohibiting hospitals from dumping homeless patients back onto the streets after they had undergone surgeries or other major medical procedures.

With a price tag of about $240 per day, respite care is an economical choice for treating homeless patients who no longer need hospital-level care, which averages $1,500 per day. The program is expected to cost about $2.5 million per year to operate. Seven King County hospitals are contributing to the program, and funding has come from other sources as well, including King County mental illness and drug dependency funds, United Way, and federal stimulus money for capital renovations.

“Respite is a no-brainer," said Christine Hurley, respite care project manager for Public Health-Seattle & King County. “It’s better for patient outcomes, and it’s cheaper. Hospital stays are cut in half” in duration, “and readmissions decline.” But in the U.S. “respite is not considered a traditional form of health care. It’s not one of the health services on the list of compensated care, nor is it an accepted housing approach.” So it’s difficult to establish an effective respite program.

Six years ago, however, four Seattle hospitals rose to the challenge. Harborview, Swedish, UW, and Virginia Mason made the decision to work together on establishing and staffing a new respite program for homeless patients discharged from any of their facilities who need recuperative care. Valley, Evergreen, and St. Francis hospitals joined the project more recently.

Public Health facilitated the collaboration among the hospitals. “It’s unusual for a private hospital to pay another organization for patient care,” Hurley said, and different entities have different kinds of restrictions. Thus, for example, merely negotiating the lease took a whole year. The county health department became “a neutral convener, to bring the parties together and then to be the developer — to get more partners and more funding. When nobody else is willing to take the risk” of developing a necessary but complex project to benefit society, she said, public agencies are often willing to step in. The department has been spearheading the project for four years.

Seattle's largest respite facility opened Sept. 12 on Jefferson Terrace's remodeled seventh floor. Jefferson has 300 residents, many of whom were homeless in the past and have struggled with mental health or addiction issues. After having worked hard to build more stable lives, said Hurley, the existing residents weren’t thrilled at the prospect of a lot of ill, homeless people moving into temporary beds down the hall. “Some of us might say, 'Hey, they’re poor, they should just not care,'” she said, but SHA worked to find a way to protect the hard-won stability of existing residents by physically dividing the new program from the rest of the building.

A separate front door to a secure elevator accessing only the seventh floor was installed. Single studio apartments were converted to 16 spartan rooms with two or three beds and a bathroom. In a shared community room, patients eat three meals a day delivered by FareStart.

The program includes helping residents find homes once they've healed enough to be ready for them. "The goal is to keep them as long as we can while they need medical services, and get housing for them afterward," Hurley said. Respite care has been shown to break the cycle of repeated homelessness and to improve people’s chances of success at living independently in supportive housing.

King County's Committee to End Homelessness played a part in developing this aspect of the project. CEH director Bill Block helped persuade United Way to provide what Hurley called “a totally vital $200,000 for the lease,” despite the fact that the agency doesn't usually fund health care projects, which have relatively strong support from other sources. Said Block, “We talked about this as a portal to housing some of the most service-resistant people. Folks on the street often have a lot of resistance to becoming involved with mainstream systems. But when they’re sick, it’s a point of high vulnerability, and it’s a moment when they can be persuaded to accept housing services.”

Still, Hurley said, "our weakness is the back door. We need more supportive housing.” Sometimes the best that a respite program can find for a recovered client is a place in a shelter until a home becomes available.

Respite care fits with an emerging model of American medical care, in which different care providers work together to help clients needing particular combinations of services and support, said Hurley. At this juncture nationally, she said, “we are a health care system and a society siloed around reimbursement instead of around patients. We don’t build care around the needs of individuals, but around reimbursable services. That makes it inflexible. Medical respite is an innovative response” to a complicated set of needs. 

“The program has universal appeal” to partisans on either side of the political divide, she added. “It’s the right and just thing to do. And it provides higher quality of care at lower expense.”


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