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What Montefiore's 300% ROI from social determinants investments means for the future of other hospitals

The New York City health system created a program focusing on housing homeless patients that has already reaped big rewards.

Susan Morse, Managing Editor

Montefiore provides housing and respite care beds through facilities such as Comunilife, a community-based health and housing service provider.Montefiore provides housing and respite care beds through facilities such as Comunilife, a community-based health and housing service provider.

Montefiore Health System in the Bronx has tackled the social determinants of health by investing in housing, a move that has cut down on emergency room visits and unnecessary hospitalizations for an annual 300 percent return on investment.

"The lowest I've seen is 300 percent ROI, some years it's higher," said Henie Lustgarten, consultant and president of the Bronx Health & Housing Consortium, an organization Montefiore helped to develop.

Investing in the social determinants of health is becoming more commonplace even as hospitals and physicians ask whether it is their place to step outside of traditional care to not only look at, but try to fix, other reasons that keep patients from getting better.

Value-based care and managed care has spurred many to realize that food insecurity, isolation, lack of housing and other factors must be addressed in their populations for continuity of care to succeed as a real goal.

For many hospitals, buying food and investing in housing becomes less expensive than having a patient return to the emergency room numerous times a year. 

The big opportunity for any hospital 

America's Health Insurance Plans has shown that payers support social determinants issues. By collecting information from members about their social determinants and running that up against claims and other data, insurers can get a more complete picture of members' health, and opportunities for improvement, AHIP said in blog posted Monday.

Addressing social determinants has led to a 26 percent decrease in emergency spending, AHIP said, citing a recent U.S. News op-ed by Ken Burdick, CEO of WellCare Health Plans.

The WellCare findings saw an additional 10 percent reduction in healthcare costs – equating to more than $2,400 in annual savings per person – for people who were successfully connected to social services compared to a control group of members who were not.

New companies such as Town Hall Ventures, which invests in healthcare technology and service companies, and Socially Determined, which works with providers to save money, are addressing the need in efforts made easier through innovative Medicaid models. 

Getting physicians onboard may be a harder struggle due to burnout, 15-minute appointment times and lack of compensation for this type of assistance, according to the results of  an American Journal of Managed Care survey of 621 physicians published in June.

About 66 percent of physicians said they believed assistance in arranging transportation for healthcare would aide their patients to a great or moderate extent. Another 48 percent indicated that help with food security would benefit their patients and 45 percent reported that assistance with affordable housing would help their patients. 

But 84 percent reported that they were not responsible for assisting with food security and 69 percent said they were not responsible for arranging transportation, the AJMA survey found. Addressing the social determinants must seek to reduce, not exacerbate, the burden on providers, the report said. 

How Montefiore made it happen

Montefiore's housing costs the hospital about $140 a night per bed, which is less expensive than an overnight hospital stay. 

And it frees up an inpatient bed for someone else, said Deirdre Sekulic, assistant director for Social Services at Montefiore Health System.

The urban Montefiore in the Bronx has less of a homeless population than might be imagined, according to Sekulic and Lustgarten. There are fewer homeless here than what is seen at Bellevue Hospital in Manhattan, for example.

But looking at social determinants is not just for urban hospitals. Suburban and rural hospitals would recognize what Sekulic said was a large problem - the potential for the breadwinner in the family to face homelessness due to an illness that prevents him or her from  being able to work.

In many cases, patients don't start out homeless, but lose their jobs as they battle cancer and find themselves without a place to live, Sekulic said.

Before 2009, when Montefiore hired Lustgarten, releasing patients from the hospital who had nowhere to go except for a shelter did not only not feel right, but was expensive. In many cases, these patients became high utilizers of the emergency department.

"It was a really big issue," Sekulic said. "At the time, there was a high referral to the shelter system."

For patients who came to the emergency department, it could take a good six weeks at that time to get them back to the shelter. What's more, many patients would be readmitted to the hospital.

"We would send them back to a shelter and they'd end up back in the ED," Sekulic said. "It was a never-ending cycle, we weren't providing continuity of care." 

Lustgarten started her job by looking at the high utilizers of the ED and what could be done to avoid readmissions. The data analysis showed that the issue that kept coming up was housing. 

Lustgarten created an alert system to flag patients at risk of homelessness in real time as they entered care.

Montefiore hired a care team of two social workers to join with Lustgarten and kicked off a hospital-wide coordinated effort to make the Housing at Risk Alert System program succeed. Montefiore already has a well-established accountable care organization focused on illness prevention and wellness so the structure for a collaborative system was already in place. 

Physicians, nurses and the care team looked for triggers for homelessness. If people were giving a shelter as their address, that was one. Patients using a specific doctors who treated the homeless population was another.

Patients going to the oncology department were asked if they were the head of the household and if they were at-risk for eviction. Even if the patient had already filed for disability, it can take more than a year for payments to arrive. 

And then there were patients who had given a relative's address as their own, but upon discharge said they had no place to go. 

The social workers got involved in in discharge planning. Real conversations began happening that took away some of the stigma of being homeless, Lustgarten said. 

Tangible results at Montefiore

The program resulted in 900 to 1,000 alerts per year. Most of the patients have chronic conditions such as hypertension, heart failure, sickle cell anemia, diabetes, a lack of dialysis treatment and substance abuse.

For housing, Montefiore originally relied on what was available in the city to lease.  

New York State invested Medicaid dollars into housing which opened up 20 housing units for Montefiore's chronically ill.

Respite facilities also offered temporary shelter, with the average stay of an expected 60 days lasting 160 days.

Beyond the respite care and the 20 housing units, there was nothing more stable for folks, Sekulic said.

Montefiore helped to develop the Bronx Health & Housing Consortium in 2011. It bought four beds to house patients for up to a year. Other organizations, such as insurer UnitedHealthcare, also purchased beds. 

As New York City is investing in 90 new shelters, Montefiore is looking into acquiring more respite beds and more permanent housing.

"Another 20 beds per borough would do a lot to alleviate the housing stress of  people who are in the hospital," Sekulic said.

Discharging patients has become less stressful on staff too and, as such, morale has increased.

"Now we're much more engaged with patients, we can refer them to the care team," Sekulic said. "We've never heard from anybody in Montefiore, why are we doing this?"

The health system even goes to court over housing issues on a patient's behalf when needed. One case involved a man who needed a liver transplant, who couldn't work due to his illness and was facing eviction. He needed to get on the liver transplant list, but first needed to show he had a place to live. The transplant physician asked the judge for more time while social workers worked with the man's landlord to keep him housed.

"If evicted, it was a death sentence for this man,"  Sekulic said.

Other health systems considering similar investments in the social determinants need system-wide support from the C-Suite to the data analytics team to physicians and nurses.

The care team cannot be formed out of staffers' regular jobs, according to Lustgarten. Hospitals need to hire at least a three-person team of a project manager and two social workers who have housing as their only job.

"Housing," Lustgarten said "is as complicated as the body."

Twitter: @SusanJMorse
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