If Ray Kuziel had broken his foot this time last year, he might be spending his days limping around New Haven, waiting for the homeless shelter to open for the night. Or he’d be back in the hospital. Now a new approach to caring for New Haven’s homeless is giving him room to heal.
Kuziel is one of the first people to take advantage of a “medical respite” program at Columbus House, the homeless shelter at 586 Ella T. Grasso Blvd.
The pilot program, which opened in October, provides 24-hour housing and services for homeless people following hospital discharge in an effort to reduce re-hospitalization.
The approximately 700 homeless people in New Haven account for a disproportionate percentage of hospital stays. According to Alison Cunningham (pictured), Columbus House’s executive director, there had never been a system in place to help them recuperate after getting out.
“Historically we’d get a call from the hospital saying, ‘So-and-so is coming out and he really needs to stay in,’” she said. “Well, ‘stay in’ means you sit up at a dining room table because we don’t have monitors to check the building all day.” Like most shelters, Cunningham explained, Columbus House shuts down operations during the day to encourage clients to stay active, attend programs and look for jobs.
“That makes sense,” she said. “But it doesn’t make sense for those people who are coming out of the hospital after having surgery or having a serious illness.”
For those people—too sick for the streets or a traditional shelter, not sick enough for inpatient hospital care—the lack of somewhere to recuperate leads to a cycle of homelessness, to hospitalization, back to homelessness: A patient is hospitalized, then discharged to the streets or a shelter; his condition doesn’t improve, or worsens, and he goes to the emergency room; and he ends up being readmitted to the hospital, where the cycle starts anew.
In addition to the obvious harm to the patient, this cycle has serious consequences for the state budget. Homeless patients, whose medical costs are mainly covered by Medicaid, tend to have longer hospital stays than comparable non-homeless people. That’s partly because hospitals, unwilling to release people who have nowhere to go, often keep them longer than is medically necessary.
“Yale-New Haven has worked very hard in the past few years to make sure that patients aren’t discharged to the streets,” Cunningham said. “And so they’ll call us and if we don’t have a bed available that day they may very well hang on to that client another day or two until there’s a bed open. That’s an expensive thing to do.”
The costs are increased even more by the dramatically higher hospitalization rate among the homeless population. A 2012 study by Yale-New Haven Hospital found that 30-day readmission rate among the homeless population was 53 percent, compared to only 14 percent for other patients. The combination of longer and more frequent stays leads to “costs that are orders of magnitude higher than average Medicaid
patients in Connecticut,” the study concluded.
The Columbus House respite program aims to break this harmful cycle. Though it is not a medical facility, residents receive regular nurse visits, while healthcare navigators make sure they obtain—and take—whatever medication they’ve been prescribed. Meanwhile, the shelter’s case managers work with clients to secure benefits, get them on permanent housing lists, and look for employment.
The staff also connect patients with primary care doctors, a potentially crucial step. Cunningham explained that homeless people’s reluctance or inability to see primary care doctors contributes to their overuse of hospitals.
For Kuziel, a 55 year-old whose only income is Social Security benefits, the respite program services have been indispensable. A few months ago, he shattered the bones in his right foot in an accident, leading to two and a half weeks in the hospital. Now able to walk with a cane and his foot in a boot, he’s been at the respite program for two months. He spoke appreciatively of the visiting nurse and the navigator’s efforts to make sure he takes his medication and gets prescription refills.
“They’ve always been there for me,” he said, adding that the staff had arranged for him to live in On the Move, a transitional housing program also located at Columbus House, after he recovers from the foot injury. “They help in so many areas. There’s a lot of people here who need this.”
While it is too early to measure the results of the New Haven pilot program, data from similar efforts throughout the country suggest that Kuziel’s experience won’t be unique. A 2006 study in the American Journal of Public Health found that respite programs—also known as recuperative care—reduce inpatient visits by about 60 percent and emergency room visits by about 35 percent in the 12 months following hospital discharge for homeless patients. The staff at Columbus House are therefore optimistic about the program’s potential to improve the way homeless people’s medical needs are addressed in New Haven.
“The bottom line,” said Cunningham, “is that it’s ultimately going to save lives.”