This week, 70 San Francisco Bay Area media organizations have banded together to coordinate coverage on homelessness. The goal was to shine a bright spotlight on a pervasive problem that is only growing worse with the skyrocketing cost of living in the region.
An estimated 6,600 people live on the streets of San Francisco. Homelessness is pervasive around the Bay – from Silicon Valley to west Contra Costa County. As a longtime resident of San Francisco, I can say from first-hand experience that the problem is just as bad or worse than it was 20 years ago.
So what does this have to do with health information technology?
The homeless are a high-risk, complex care population, and significant contributors to repeat and chronic emergency department visits and hospital stays. Increasingly, health systems are launching programs tailored to this high-need population. And they are using electronic health records, disease registries and other high-tech population health tools to identify, intervene and track homeless patients.
For instance, this year, 12 public hospitals, the University of California medical centers and four district hospitals in California are launching complex care management projects. The projects are part of a state initiative called the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which requires hospitals that receive Medicaid funds to achieve performance milestones, and encourages them to try innovative care delivery models. Among the requirements for the complex care project (which started in January) is to “establish data analytics systems using clinical (e.g., EHR, registries), utilization and other available data (e.g., financial, health plan, zip codes), to enable identification of high-risk/rising risk patients for targeted complex care management interventions, including the ability to stratify impact by race, ethnicity and language.”
With the widespread adoption of EHRs, many hospitals and health systems now have the ability to identify high-risk patients (including the homeless) for targeted care management interventions. EHRs can tag patients with no fixed address for interventions with social workers and other services during ED visits. Projects are also underway that use electronic databases to link high-risk patients with community resources including housing, food banks and childcare.
Josh Harkinson of Mother Jones magazine wrote a terrific feature on an algorithm that Santa Clara County is using to predict which homeless people will use the most public services, including emergency departments. His colleague at Mother Jones, Nina Liss-Schultz, has a great piece on medical respite services for the homeless who are high ED utilizers. Barbara Feder Ostrov writes that there is a growing effort to use “digital technologies — particularly cellphones — to improve the health of Americans who live on the margins.” She offers a look at some of the initiatives.
Unfortunately, care models for high-risk patients are typically not reimbursable in the traditional fee-for-service environment. A 2015 paper by researchers at Harvard Medical School and Partners HealthCare in the Journal of the American Medical Association points out that alternative payment models such as accountable care organizations can help spur growth in programs for high-risk patients.
Questions for journalists:
- Are hospitals in my area using EHRs and disease registries to identify and reach high-risk patients, including the homeless?
- What other programs do my local health providers have in place to help the homeless?
- Are health providers working with community agencies, health departments, social services and not-for-profits in my area to coordinate help with the homeless? Are they leveraging computer databases and other technology to accomplish this?
- How are hospitals facilitating care transitions for the homeless? Are hospitals and outpatient services coordinating care to reduce readmissions and improve outcomes?