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Hospital to Housing (H2H)


It’s one of those rare win-wins in which everyone steps forward depending on the need.

Randy Jotte, MD, H2H physician advisor and associate professor of emergency medicine at Washington University School of Medicine

Last spring, well before the beginning of the COVID-19 pandemic, Barnes-Jewish Hospital and St. Patrick Center became partners in an innovative pilot program to provide apartments to homeless patients who frequently seek shelter in the hospital’s emergency department (ED).

The aim of the program was to move vulnerable individuals into stable, long-term housing, address the critical social and health care services they need, diminish unnecessary use of hospital services and hopefully, reduce hospital costs.

The program, called Hospital to Housing (H2H), was launched on May 1, 2019, with a two-year grant from The Foundation for Barnes-Jewish Hospital. Metrics show encouraging results with a significant decline in participants’ ED visits.

“It’s a huge success in a health care area where we never thought we’d see success,” says Randy Jotte, MD, the H2H physician advisor and associate professor of emergency medicine at Washington University School of Medicine.

“It’s one of those rare win-wins in which everyone steps forward depending on the need.”

And now, as the COVID-19 pandemic places even greater demands on the ED and the spread of the virus must be stopped, Dr. Jotte says the program is more important than ever.

“As we all know, avoiding infection with COVID-19 requires frequent handwashing, avoiding high-touch surfaces and staying home,” he says. “None of these are options in the homeless population. The CDC reports that up to a quarter of homeless shelter residents were infected with COVID-19 when tested, much higher than we’d find in the general population.”

He notes that the homeless often have multiple chronic medical conditions so that if they become sick with COVID-19, it can be severe, requiring admission to an ICU.

“The people in the program are staying inside their apartments,” he says. “Their contact with the general public is much more limited than if they were wandering outside, visiting multiple shelters. It’s a service to the entire community.”

The St. Louis program is based on a successfully implemented model started by the University of Illinois Chicago Medical Center in 2016. At the end of the first year, 90 percent of the Chicago participants remained in stable housing and had improved health outcomes.

To be considered for the St. Louis program, patients must lack a permanent nighttime address, be frequent emergency room users and have a substance use problem and/ or mental illness. The combination of these conditions means that they suffer from a complex set of social and medical issues that can often lead to behavioral problems.

“These are people who everybody gave up on. Their cases are so challenging. It takes a lot of organization and resources,” Dr. Jotte says. “They are very socially isolated, most are single and when asked to list emergency contacts, they either list nobody or their case manager.

“You have people who come to the ED because they need safe shelter, they need food,” he says. “And then you have a subset who need socialization. They don’t have anyone else and they are so thirsty for human contact.”

To determine candidates for the program, patients are screened by the Barnes-Jewish Hospital’s ED medical staff and Case Management Services social workers. Individuals who agree to participate are referred to St. Patrick Center, which provides them with housing, food, assistance with coordinating medical care and other important services.

The first phase of the program is set up to handle about 20 patients, and there are now metrics for the first 15 participants. Those patients primarily range in age from 50 to 64 and most are men with both cognitive impairments and substance abuse issues. While participants averaged 40 ED visits per year at Barnes-Jewish Hospital before enrolling in the program, metrics for the first six months for the May 2019 enrollees showed that these patients’ ED visits were cut by 53 percent after receiving permanent housing. Inpatient days dropped 67 percent and readmissions to the hospital fell 42 percent.

Dr. Jotte says that Barnes-Jewish is closely monitoring the financial impact of H2H and that preliminary data shows these declines in visits are reducing unnecessary costs to the hospital. And while he had some initial concerns that a drop in visits to Barnes-Jewish would result in increases at other BJC hospitals, that isn’t the case. In fact, the entire BJC system is benefitting.

“We’ve tracked emergency department visits and hospital stays not only at Barnes-Jewish but also throughout the BJC system and regionally,” he says. “Visits to the emergency department and inpatient stays have dropped everywhere for these patients. It’s remarkable.”

Much of the credit, he says, goes to St. Patrick Center that has a long history of providing help to the homeless in the St. Louis area. With its network of more than 200 landlords, it has been able to find apartments for the H2H participants in a matter of days.

“Once placed, the patients are closely case-managed so that their outpatient needs are being addressed in a timelier manner than if they went to the ED,” says Diane Howard, MSW, LCSW, who supervises the emergency room social workers. “The quick turnaround is unheard of in the social services field, where two months placement would be considered lightning speed. It blows me away and I’ve been doing this for 20 years.”

Dr. Jotte says he is grateful that St. Patrick Center is keeping H2H operating, particularly in this very difficult time.

“We will get through this and this pilot program for the homeless will continue,” he says. “Is this program worth the effort or not? It clearly is.”