Homeless populations face numerous barriers to receiving quality healthcare. Existing health problems and chronic diseases are often exacerbated in these living conditions, while the risk of communicable diseases and violence is increased. Additionally, homeless patients often seek care through emergency departments and have longer and more frequent stays, complicating hospitals’ efforts to provide effective treatment and driving up costs. New York City has the largest homeless population in the country. In 2018, NYC Health + Hospitals began an initiative to help identify and better address the health needs of the city’s homeless population.
Interdepartmental staff, including social workers, emergency room doctors and service providers for the homeless determined proxy indicators for homelessness and where such information could be found within the different information systems of the health system’s hospitals. From there, they created a composite definition of homelessness by:
They then incorporated the homeless flag into an overall score predicting risk of high hospital use, which is deployed to frontline providers using electronic medical records.
Using this definition, they were able to identify more than 20,000 adult homeless patients served within one year across the health system. The findings revealed important sub-groups among homeless patients, informing the various kinds of care and treatment that groups within the homeless community need. Additionally, they used the data to compile lists of patients who meet eligibility criteria for local supportive housing complexes, such as people living with HIV/AIDS or with behavioral health diagnoses, and helped assist with housing applications. They also work with sister New York City agencies to match high-risk homeless patients to a city housing agency database to verify approved housing applications and identify needed follow-up. Profiles of homeless patients are shared with managed care plans so that they can be active partners in care management and support discharge planning for inpatients.
Read NYC Health + Hospitals’ article in the Harvard Business Review to learn more about the work they’re doing to provide quality care to their homeless patients.
For more information, contact Laura Jacobson, program manager, data services, office of population health, at email@example.com.