Housing Is Healthcare for Homeless Patients in Tarrant County, Texas

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Housing Is Healthcare for Homeless Patients in Tarrant County, Texas

Since 2015, four organizations in Tarrant County, Texas, home to the city of Fort Worth, have been working together to house homeless individuals with a history of overusing the emergency department (ED) at the John Peter Smith Health Network (JPS). Called Pathways to Housing, the program is the county’s first implementation of a Housing First approach to medical care for people experiencing homelessness. By providing the stability and security of a home, Pathways is reducing the number and expense of ED visits among the high-utilizer population, improving the health of program participants, and connecting people with other services and resources needed to improve their lives. The collaboration among JPS, a primary safety net provider for uninsured patients in Tarrant County, local Medicaid provider Amerigroup, The Salvation Army Dallas-Fort Worth, and the Continuum of Care lead organization Tarrant County Homeless Coalition (TCHC) exemplifies how critical housing is for dramatically improving the quality of life of those experiencing homelessness.

The High Cost of Emergency Care

At its core, the problem is simple enough: people are using the hospital’s high-cost emergency services for nonemergency needs or for chronic conditions that would not become medical emergencies if properly managed. The effects of this treatment model include suboptimal medical outcomes for patients; increased costs for Medicaid insurers and, ultimately, taxpayers; and overburdened hospital emergency resources. A 2015 analysis found that 24 high-utilization homeless patients at JPS generated ED costs in excess of $900,000 in a single year. In the years before the launch of Pathways to Housing, members of the soon-to-be partnership started working independently toward solutions to this problem. For example, to curtail unnecessary ED visits and contain costs, JPS launched the Care Connections team to provide on-the-street medical care. Meanwhile, Tammy McGhee, currently executive director of TCHC and then a coordinator of homeless services for the county, hoped that engaging other stakeholders might produce a more comprehensive solution than Care Connections had been able to achieve.

According to Joel Hunt, physician assistant at JPS and coordinator of the Care Connections team, homeless individuals may rely on emergency services as their primary means of accessing care for several reasons. Many are not enrolled in any form of insurance, including Medicaid. Similarly, people living on the street may not be connected to traditional structures for accessing primary care and may find the steps needed to organize their care that way daunting. Hunt also reports that the perception of safety is a factor, with high utilizers knowing that whatever their needs, the ED will be equipped to ensure their survival. Perhaps most profound, according to Hunt, is the “humanizing effect,” when patients become familiar with ED staff and feel seen, and they may be physically touched in kind and reassuring ways.

Prescription: Housing

Although stable housing and wraparound services are fundamental to addressing the medical and behavioral problems that can lead to high ED utilization among persons experiencing homelessness, finding ways to build sustainable programs on top of existing institutional infrastructure can be a challenge. Part of the task in developing the Pathways program was determining a workable division of labor among partners that takes advantage of each partner’s competencies. Amerigroup identifies high utilizers of ED services to be considered for the program, and JPS then identifies which of these potential participants might be homeless. The Salvation Army verifies the list through outreach to individuals and enrolls those who wish to participate. The Salvation Army also initiates the process of securing housing with the help of TCHC, which in addition to administering Pathways to Housing’s funding, manages the county’s coordinated entry system. Arranging housing for the Pathways program is a natural outgrowth of the Salvation Army’s work over the previous decade to find permanent housing for clients in other programs. These efforts built good working relationships, according to Beckie Wach, executive director of the Salvation Army Dallas-Fort Worth, and landlords proactively reach out to her organization when vacancies are about to occur. The housing is scattered throughout the county, which helps individuals better integrate into society by avoiding concentration. Using scattered housing also allows the program to consider patients’ preferences about where they would like to live.

While patients are participating in Pathways to Housing, they receive team-based care and services; the partner organizations speak weekly to review the progress of each patient and coordinate each organization’s activities. In the beginning, the service providers’ engagement with program participants is intensive. Case managers from the Salvation Army make daily contact during a patient’s first month in new housing. The focus at this stage is on implementing a plan to ensure that the patient’s most immediate needs are being met. Behavioral case management, if needed, is provided by Amerigroup. The Care Connections team contacts patients weekly based on their health needs. Hunt says that this work is fundamentally about using in-home visits to recreate the psychological, humanizing support these patients find in the ED within the context of housing, ensuring that the patients feel safe, secure, seen, and cared for. Between the second and sixth month, the caseworker is expected to connect the patient with appropriate services and help them find a nonemergency medical home. The goal is for patients to no longer require the intensive support of Pathways to Housing by around the one-year mark, with their medical care directed by a primary care physician. Physician-managed care can involve more steps and thus more planning than emergency-centered care, so through experience, patients become better able to navigate the healthcare system.

Building on a Successful Program

A HUD Supportive Housing program grant complemented the expertise and capacity of JPS and its partners, enabling them to provide service and housing for up to 14 people at a time. The 3-year grant funded housing with intensive support and case management services for 39 patients. Program participants reduced their ED use by 30 percent — in line with studies of similar Housing First medical programs — and reduced costs by $1.6 million annually. Further mirroring the results of similar programs, 69 percent of Pathways participants remained successfully housed after a year; each patient reduced their ED usage, and JPS is currently studying the effect of the program on participants’ mental health and chronic conditions. Following the program’s success, HUD awarded the partnership a $433,938 grant to continue existing levels of service through 2020 and another $220,968 to expand the program to reach 15 more high-utilization ED patients experiencing homeless. In addition, JPS and its partners continue to research other ways to meet the needs of Tarrant County’s most vulnerable population, and they are examining ways to intervene in other revolving-door social systems, including the prison system, by placing supportive housing at the center of the model of care.