Modern Medicaid Alliance Featured Medicaid Solution: UPMC for You – Cultivating Health for Success
There are several contributing factors that hinder individuals who are homeless from receiving adequate medical care. Barriers to health care within the homeless population include inability to pay, lack of knowledge about where to seek treatment, lack of transportation, and difficulty completing forms. Underuse of preventive and primary care services leads to mostly unplanned interventions in a costlier setting. This further contributes to poor health outcomes, high health care costs, and inadequate coordination of care for this high-need population. As a Medicaid, physical health managed care organization, UPMC (University of Pittsburgh Medical Center) for You does not have direct access to information regarding the housing status of its members. However, through interactions with medical providers and hospital discharge planners and members, the medical care coordination staff has estimated that at any given time approximately 40 to 50 of its Medicaid or Special Needs Plan members are homeless. Although staff would typically refer such members to local housing programs, placement was often delayed by lengthy wait lists. Additionally, coordination of care for these members was hindered by lack of established communication channels between the U.S. Department of Housing and Urban Development (HUD) and the UPMC for You Medicaid Plan.
In partnership with Community Human Services, a local HUD vendor that provides an array of housing and related support services, UPMC for You launched the Cultivating Health for Success (CHFS) program in 2010. The program is structured to improve health care for eligible members through a collaborative, team-based approach that integrates three components—permanent housing, an assigned medical home and intensive case management and care coordination. The goal of the program is to provide participants in the initiative with a secure living environment and social supports; timely and coordinated medical care; in-home assistance with activities of daily living; consistent medical monitoring; and basic life skills training. Individuals are eligible to participate in the CHFS initiative if they are homeless, have a medical disability, are enrolled in the UPMC for You Medicaid or Special Needs Plan, and have at least one year of high health care expenditures including unplanned services (emergency department use and unscheduled hospital admissions and re-admissions). Program participants are seen at a primary care office, as well as by a community-based registered nurse and social worker to better enhance case management.
Individuals that were previously homeless and now stably housed through CHFS saw declines in medical costs and unplanned care. Rates of primary care and specialist visits doubled after program enrollment and pharmacy costs increased, suggesting improved medication adherence. More specifically:
During the first five years of the program, 51 of 60 enrolled members were successfully housed through the CHFS collaborating organization. To offset the direct cost of the program at $150,000/year, 24 members must be successfully housed annually.
After housing was attained, medical cost savings averaged $8,472 per year and pharmacy costs increased $2,088 per year, resulting in an overall cost savings of $6,384 for each housed member.
Analysis from the CY2015 and CY2016 cycle indicated housed HUD members had 42% less unplanned claims compared to the non-HUD members. Pharmacy costs increased 1.5% suggesting continued improved medication adherence. Although not statistically significant, HUD members had a 9.3% lower gap in care, demonstrating an increase in quality of care.
As intended, the rate of doctor visits rose after member enrollment compared to that of before the program. The increase in pharmacy cost likely reflects an increase in pharmaceutical use aimed to better control physical and behavioral symptoms. The decrease in medical cost is related to decreased usage of inpatient facilities, particularly ED visits. This also indicates medical care is now more so being performed in an outpatient setting as opposed to an inpatient facility. In addition, members receive better preventive care and less unplanned care to those who are not successfully housed.
Members who were enrolled but not yet housed experienced an increase in medical spend suggesting that savings only occur when members are in a stable living environment.
Members who graduated from the program had an increase in unplanned spend after graduation, suggesting that members should be contacted periodically to maintain care coordination and to address any new issues that might arise.
Real Life Example of Success:
Barry, Age 60: Barry, joined CHFS in April 2014. He returned to his native Pittsburgh from Florida in 2011, but his aged parents asked him to leave their home due to his alcoholism. His drinking increased even more after his father was shot in the head during a convenience store robbery and remained on life support for more than a year before dying. Unable to pay his rent, Barry was evicted and became homeless. Barry has maintained sobriety since a stay in detox and rehab in July, 2015. His medical cost and unplanned visits drastically reduced after being housed in the program. He now lives in an apartment, interacts several times a week with peers, utilizes a gym and participates in offered social activities. He has visited the ED a few times during his enrollment, but has had no inpatient stays.
John G. Lovelace
President UPMC for You
President of Government Programs and Individual Advantage, UPMC Health Plan