Pilot Medical Program Aims to Provide Patients Experiencing Homelessness Transition From Care Facilities to Stable Temporary Housing

Jaime Bland, DNP, RN, President of CyncHealth, explains why today’s health care system is not equipped to meaningfully support the complex health needs of people experiencing homelessness, and highlights how a a 24-month pilot medical respite program will impact local patients and hospitals in several ways.

Tell us about yourself.

I’m Jaime Bland, DNP, RN, and President and CEO of CyncHealth. CyncHealth is the state-designated health information exchange (HIE) for Nebraska and Iowa, connecting the providers of over 1,135 facilities to timely and accurate health data of over 5 million people. CyncHealth’s mission is to empower healthier communities through steadfast pursuit of advancing interoperability, bringing data democratization, cultivating economic value and delivering a health data utility. HIEs like CyncHealth are at the forefront of interoperability across organizations that support the local needs of communities and stakeholders.

Since being appointed CEO in 2018, the organization has focused on transforming the HIE to become a regional health data utility (HDU). An HDU is an entity that serves the health data and analysis needs of its state and/or region — both the health care private-sector (providers, payers, employers) and state government entities. Like the electric utility model, responsibility for connectivity & interoperability is given to a public-private partnership designated by the state to operate a regulated network over which everyone can transmit health information. This public-private partnership leverages the agility and innovation of the private sector to support critical public health needs, coordinating with public health departments (state and local) and Medicare/Medicaid to enhance connectivity to serve the public good and inform policymakers. By empowering one entity to link, match, aggregate, de-duplicate, govern and share health information, efficiencies are gained across the entire health ecosystem.

My drive for health data interoperability stems from being a registered nurse and experiencing first-hand the value data can have in ensuring better outcomes for people, controlling costs, and reducing the burden on providers. I earned my Doctorate of Nursing Practices in Public Health Nursing from Creighton University and serve as the board officer of the Consortium for State and Regional Interoperability (CSRI). I’m also a board member for the Zorya Foundation, Civitas and a member of other related committees. Through these experiences, data and governance of information have evolved into a passion.

What unmet need(s) inspired the Health and Dwelling medical respite program?

Today’s health care system isn’t equipped to meaningfully support the complex health needs of people experiencing homelessness. These individuals often face increased rates of behavioral health diagnoses and chronic conditions such as hypertension, diabetes and heart disease. Because they typically have limited options for care, emergency departments (EDs) often serve as a source of primary care for the unhoused community. Utilization of EDs for primary care increases the burden put on already overwhelmed health care teams, leading to provider burnout and long wait times for those seeking care for emergent conditions. Unfortunately, few patients experiencing homelessness will ever see their health concerns resolved, as most require follow-up care that EDs cannot provide.

Studies shine a light on how dire today’s situation truly is. According to 2019 data reported by the Metro Area Continuum of Care for the Homeless (MACCH) Omaha, around 24% of the population served by MACCH reported three or more health conditions upon entry into their system. Of these, 126 individuals reported they had stayed in a hospital before coming to an emergency shelter; another 105 indicated they came from a psychiatric hospital or facility. A CyncHealth assessment of deidentified medical records from all hospitals in the Omaha area in 2020 showed that individuals experiencing homelessness averaged 44 hospital visits per month, with an average length of stay of 5.5 days and more than 2,000 readmissions. The top co-occurring health conditions experienced by this population were depression, hypertension, chronic kidney disease and diabetes. The majority of hospital admissions were for substance use disorder (SUD), mental health exacerbations and chronic disease.

Another study found the average homeless person visits the ED five times per year at an average cost of $18,000 to taxpayers. Among unhoused patients with the highest number of ED visits, costs rise to more than $44,000 a year, with national expenditures totaling nearly $10 billion a year.

This expense puts an enormous strain on our health care system. Furthermore, because EDs are not equipped to solve chronic conditions, patients who are homeless do not receive adequate care, creating a cycle of encounters that is expensive for the system and burdensome for both the patient and providers. These patients are also struggling with greater social determinants of health (SDOH) challenges than their peers, like lack of transportation and food insecurity—resulting in a wide range of health, quality-of-life and ability-to-function outcomes.

SDOH, such as homelessness and housing instability, are both drivers of poor health outcomes and increased health care utilization, which in turn raises the cost of health care across the board. Medical respite programs have been proven to shorten hospital length stays, reduce hospital readmissions, improve health outcomes of participants and lower overall costs of care.

Can you share some details about the program? What organizations are involved, and how is the program designed?

CyncHealth partnered with Charles Drew Health Center and Siena Francis House to launch “Health and Dwelling,” a 24-month pilot medical respite program. The pilot program is the first medical respite program in Nebraska and is funded by a grant through CHI Health Foundation. Through the program, medical care will be provided by Charles Drew Health Center with services including post-acute care, behavioral health, dental care and pharmacy services. Siena Francis House will provide shelter, food, clothing and other personal needs, case management and support services. CyncHealth will provide the IT infrastructure to support the program.  

How do you anticipate the program will impact local patients and hospitals?

The medical respite program will impact local patients and hospitals in several ways. Homeless patients will gain safe shelter to fully recover from their condition, which will lead to reduced readmissions for hospitals. By moving to a lower care setting, hospitals will be able to use those beds for other patients, which will help ease the burden on EDs and hospitals—easing physician burnout by freeing up limited resources and redirecting them to patients and staff who are more equipped to help. Finally, since these patients are generally uninsured or on Medicaid, the program should lead to reduced expenditures for health systems and public health programs.

CyncHealth conducted an internal analysis that identified some striking results on rehospitalization impact. Studies showed that 30%-50% of patients avoid rehospitalization when providers use the HIE. In SFY22, 191 hospitals provided care to Nebraska Medicaid beneficiaries with an expenditure of $379,133,926. While nearly all hospitals and health systems participate in the Nebraska HIE, with an average of 500,000 queries per month, if just 10% of providers use the HIE to reduce unnecessary inpatient hospitalizations by leveraging immediate, actionable clinical insight into their patients, the cost avoidance would total nearly $38 million.

The effect on EDs was just as dramatic. A recent study found that unplanned hospitalizations dropped by 10% and ED visits by 13% when providers used the HIE to inform care. The impact isn’t just anecdotal. For example, the state of New York reported an annual savings of $160-$195 million on health care spending in 2019, largely because of that state’s work cutting down preventable ED visits.  

Is there anything else you would like to add?

Our community cares deeply about the health outcomes of our population. For over two years, community-based organizations and stakeholders came to the table to collaborate and plan a unique community solution. This medical respite pilot is the result of that work. Housing is health care and a core pillar of stability for patients’ health and well-being. It is critical to provide individuals facing homelessness with access to routine, consistent care, including mental health services and transportation.

Health care and social care cannot exist independently. This collaborative project allows providers and care coordinators to meet patients where they are when they need support the most.

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