Over a year ago I worked with a research group that had secured NIH funding to better understand the 30-day readmission rates at minority-serving hospitals across the country. I interviewed Chief Quality Officers, Chief Medical Officers, case mangers, and others in public, private, and teaching hospitals with a high minority patient population.
Born out of the Affordable Care Act, The Centers for Medicare and Medicaid Service’s 2012 Readmission Reduction Program penalizes hospitals with higher than expected 30-day readmission rates for pneumonia, heart attack and heart failure through reduced Medicare payments. You can learn more about the policy on CMS’s Readmissions Reduction Program webpage.
The idea is that a hospital’s readmission rate is a good measure of quality because patients who receive good care during and after their hospital stay should not have to be rehospitalized before 30 days. Some have criticized the policy, stating that it unjustly penalizes hospitals serving poor and vulnerable patients who may have a harder time managing their own care. Others believe that all hospitals, especially those serving low-income patients, should be held to the same quality standards.
In response to this policy, hospitals have been improving their case management, access to follow-up outpatient clinics, prescription adherence programs and supports, and in-home follow-up care. The study I was working on sought to understand how these efforts, or lack of efforts, impacted readmission rates in minority-serving hospitals.
Yet something I was particularly struck by in my interviews was that as much as the hospitals worked to reduce readmission rates, they couldn’t seem to move the needle for a slice of the patient population. These were the patients who seemed to never pick up their medication. These were the patients who seemed to never be able to take the medications at the right time or with the right foods. These were the patients who often failed to make their follow-up appointments, or who were never available for in-home visiting. These were the patients who seemed to walk right back through that emergency room door week after week. These were the patients experiencing homelessness.
According to 2013 study published in Medical Care, half of all hospitalizations for people experiencing homelessness result in a 30-day hospital inpatient readmission and 70% resulted in either an inpatient readmission, observation, or an emergency department visit within 30 days of discharge. And yet the tools at the disposal to hospitals to reduce their rates weren't focused on this population. Follow-up calls and in-home visits don’t count for much if you don’t have a place to call home. Eating a nutritious diet, keeping dressings clean, or following complicated prescription instructions can be incredibly challenging if you’re spending your days finding a place to sleep, staying warm under a bridge, or dealing with mental health or substance use issues. A 2012 study published in Journal of General Internal Medicine found that that 67% of patients experiencing homelessness spent their first night after hospital discharge at a shelter - another 11% spent their first night on the streets. Often heading back to the hospital is the safest option for patients; it’s a place where they feel protected and can rest.
While these patients make up only a small percentage of the patient panel in these hospitals, the time, resources and mental energy to care for them seemed to overwhelm the folks I interviewed: they were driving up their readmissions rates. There are risk-adjustments in the CMS penalty formula that seek to account for substance use and mental health issues. However, coding for these issues is inconsistent at best, and housing insecurity isn’t addressed at all in the policy.
There’s no easy answer to this problem. Hospitals generally fail to address the reasons that led to the patient’s homelessness in the first place. Some suggest that patients who are homeless be discharged to supportive housing rather than back to the streets. Another option is medical respite programs that have been shown to reduce hospital readmission rates. Yet, for hospitals receiving penalties for higher than expected readmission rates, additional resources to support these patients can be hard to come by.
It’s time we took a more realistic and nuanced view of the needs of patients experiencing homelessness – especially in light of new quality measures that may penalize hospitals serving these patients. Not only is it good care to help patients stay healthy outside of the hospital so that the emergency room bed isn’t the safest place to sleep at night, but it’s also the fiscally responsible response for hospitals and CMS. Training and tool development for homeless services isn’t enough – hospitals often do not know about these resources, and rarely are they specific to medical settings. System-wide awareness of the needs of patients who are homeless and tools to respond that are specific to a hospital setting are critical to begin to provide the support that the hospitals want, and the services that these patients need.