As a group, homeless individuals are disproportionally heavy users of hospital services.
The Queen’s Medical Center, the largest hospital system in Hawaii, counted 6,958 homeless encounters in 2013; the number rose to 11,000 in 2016, according to a 2017 report, Touchpoints of Homelessness. The financial cost has risen as well: From 2013 to 2016, Queen’s estimated it has absorbed about $40 million in unreimbursed medical costs for high-needs homeless patients.
Moreover, many of the homeless, regardless of their medical condition, obtain health care through one of the most expensive ways possible: via ambulance to the emergency room, which has become a primary point of entry for homeless people leaving the street to seek help.
“There’s such a huge capture within the emergency room, bigger than sometimes even the shelters, bigger than some of the community outreach programs,” said Queen’s emergency room physician Daniel Cheng.
For Cheng, this presents both a problem and an opportunity to bend the curve. Cheng, 37, helped establish and is now medical director of the Queen’s Care Coalition, an intensive effort launched 18 months ago to provide homeless individuals arriving in its ER not only with medical care, but with help accessing housing and social services they need to keep them healthier — and out of the hospital.
In his State of the State address last month, Gov. David Ige praised the coalition, noting that Queen’s “became the first hospital in the nation to place its most medically fragile, homeless patients into housing as part of the recovery process.”
Cheng, who grew up in Kaimuki, got his medical degree from the University of Hawaii’s John A. Burns School of Medicine, where he is an assistant clinical professor. He was named the 2018 physician of the year by the Healthcare Association of Hawaii. He lives in Manoa with his wife and son.
Question: How many homeless people receive services from the Queen’s emergency room? How does that compare to other hospitals?
Answer: 2,850 unique individuals and roughly 8,200 emergency department visits, as conservative estimates for 2018. Queen’s shoulders 65 percent to 70 percent of the homeless care for Oahu.
Q: What kinds of ailments are most common among the homeless your department sees?
A: Psychiatric and substance abuse, skin infections, open wounds and pneumonia, and trauma.
Q: How did the Queen’s Care Coalition get started?
A: I returned home in 2013 after training in Los Angeles at the USC-Los Angeles County affiliated hospital. I came home to growing homelessness and saw people dying in my ED (Emergency Department) and on the streets. A handful of social workers and myself decided these patients, human beings living in the “aloha” state in the richest nation in the world, deserve better. I Googled best practices nationwide … , cold-called the programs and hospitals, and put together a business proposal that our compassionate CEO (Art Ushijima) accepted to front the money for the project.
Q: What was the proposal?
A: If we were going to make some kind of significant dent, I really wanted a program. We needed a group of individuals, a designated place to live in, we needed IT support, we needed hardware support, we needed the ability to be out in the community …
I needed to make sure it made sense for (Queen’s) fiscally to put in some money. There is actually a reasonable amount of evidence to support that having a program using “care navigators” can actually dramatically drop utilization, and that’s where your return on investment is. Where that return on investment comes from — either the payer side (HMSA, Medicare, Medicaid), versus the hospital side versus the physician side — there’s a little bit of devil in the details there.
Q: How much does it cost to operate the coalition, and how is it staffed?
A: $1.4 million to $1.5 million a year. The complete staff consists of a medical director, three full-time social workers and one advanced-practice nurse, and 10 community navigators.
Q: What are the primary goals of the coalition?
A: To break the cycle of acute-care reliance of medically fragile homeless patients by addressing their social needs. Hospitals are not reimbursed for addressing social determinants of health — housing, food insecurity, transportation, utilities, domestic violence. Therefore these areas have largely been ignored during a patient’s care in the hospital. However, for the homeless, these issues are at the root of why they are sick. And until they are addressed, their skin infections, pneumonia or episode of psychosis will only return once they are back on the streets.
Q: Can you describe the process by which a homeless person receives expanded help?
A: It actually begins from data. On a monthly basis, I generate a spreadsheet that tells me who is utilizing the emergency-room system, who is being hospitalized into the system, what’s the makeup of these patients. So to begin with, we already know who they are, what time they come in, what they come in for, and pretty much what their medical needs are. … So I have that information pretty much already pre-sifted out and based upon that, we actually pair that (patient) with a navigator.
The next step is a mixture of lie-and-wait, and a little bit of proactiveness. We know that based on the documentation, the patient stays at Fort Street Mall, or that patient stays at Aala Park. This is what they look like. We have their picture ID. Go find that patient and address them based upon the previous encounter:
“Hey Danny, I saw you were in the ER yesterday for some toe pain. My name is Bob, I’m part of the Queen’s Care Coalition, and I really want to help you out, to see what kind of care you need, I want to follow up.”
That’s one approach.
The other approach is, we actually have real-time alerts when they come in. So that, as long as the navigator’s working, they’ll be alerted that this patient has now entered the system. … Once the medical emergency is addressed, that’s when the navigation takes over:
“Hey, we got you stabilized, we hear you’re being discharged, let’s move on to the next step. What do you need right now? Where are you going to go? What were the barriers for you not going to X, Y and Z? How can we help you pick up these medications? How can we help you pick up the food stamp application?”
And that’s where it starts.
Q: Are you making progress?
A: Yes. (It’s) accomplished by partnering with community homeless resources: shelters, mental health care providers; housing agencies and the city’s homeless program office; the community health clinics and also other areas like food stamps, bus passes, insurance plans.
Fundamentally, however, it is the work of the community navigators to build trust with the patients to allow them to be willing to accept these resources and to work toward improving their current condition, rather than accepting the habituated feeling of being ignored, feared and ostracized by society.
Q: How many homeless people have been helped through the coalition?
A: Through 13 months, 144 patients. Roughly 75 percent become sheltered (not permanent housing, but off the street), but all typically gain increases financially through new social welfare benefits they weren’t accessing — food stamps, disability income, etc. …
But I think the size and the scale (of the homelessness problem) has not quite been understood. We have roughly 10 community navigators in our system. We’re only touching less than 10 percent of the homeless population coming in through the ER. … At least 2,500 unique individuals are utilizing the emergency room each year.
Q: Has it paid off yet?
A: I don’t have the hard numbers, but preliminary data is showing what we expected, which is a significant return on investment.
Q: Anything you’d like to add?
A: I feel strongly that everyone needs to do their part, be it volunteering, donating, or supporting legislation to make a difference. The work being done by the care navigators and other community homeless services is both physically and emotionally tough, and if the people of Hawaii want to see real change happen on their sidewalks and communities, we are going to need a whole heck of a lot more of these living angels.
