Housing is Healthcare: How a PCMH is Caring for NYC’s Homeless Population

March 20, 2018
A PCMH approach at Care for the Homeless has enabled the organization to improve access to care, increase care coordination, and enhance the quality of care for the city’s homeless population.

As of January 2018, there were more than 63,000 homeless people, including over 23,000 homeless children, sleeping each night in the New York City municipal shelter system, according to statistics from the Coalition for the Homeless. What’s more, there were an additional 4,000 homeless people on the streets of New York City, per recent data from the Homeless Outreach Population Estimate.

And when it comes to receiving healthcare services, it’s clearly been a struggle for all parties involved. On one hand, having stable housing is an obvious connection to being able to stay healthy. And on the other hand, from a healthcare cost perspective, homeless individuals are more likely to use ER services than members of the general public.

There are a fair share of organizations in New York City that help the homeless with healthcare issues, with one of those such organizations being Care for the Homeless, an institution developed in 1985 with the aim to meet the healthcare and social service needs of homeless people in the city. What separates Care for the Homeless from some other organizations of its ilk, however, is that it was just recently formally recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 Patient-Centered Medical Home (PCMH). The New York City-based organization partnered with the Massachusetts eHealth Collaborative (MAeHC) to apply PCMH standards across its 14 sites.

The team-based PCMH approach gives each person who seeks treatment at Care for the Homeless a comprehensive care plan that is integrated across multiple providers at any of the organization’s health centers. Care for the Homeless’ service delivery model provides care at co-located host sites such as shelters and soup kitchens. Interdisciplinary teams visit these service sites anywhere from one to five days a week to offer certain primary care services; the system also has some behavioral/mental health and podiatry services.

What’s more, Care for the Homeless partners with other organizations, such as the Institute for Family Health, to directly treat patients at mobile health clinics across the city. Overall, the organization serves between 7,500 and 8,500 men, women and children, annually, in the Bronx, Brooklyn, Queens and Manhattan.

“We provide care to people during a very fragmented time in their life,” says Regina Olasin, D.O., chief medical officer at Care for the Homeless. “Our goal is to not just give them a medical home where they can turn to for care options, but to also provide a place that feels like a home—a warm and welcoming space where the providers know their names. When homelessness strikes, it affects more than a person’s current situation—it can expose them to major health risks with long-term ramifications. We aim to step in and help empower people with a path towards a healthier future.”

Indeed, Olasin says one of the core missions at Care for the Homeless is that “housing is healthcare,” adding that “If you look at all the data of people who are stably housed, they are doing much better on every single health parameter out there than individuals who are not stably housed.”

Undoubtedly, one of the major challenges with caring for the homeless is being able to follow them across the care continuum. As Courtney Beach, senior consultant at MAeHC puts it, “When serving a transient population with a unique set of needs, it is very difficult to track patients to ensure that they are utilizing the services or receiving information about their care.” At Care for the Homeless’ 15 sites, though, the EHR (electronic health record) allows for shared functionality, so that when a site is closed or when someone needs to be seen, the same medical record is available for all affiliated providers, and it enables the organization to provide 24/7 care with access to the EHR, says Olasin.

“A lot of the work we are doing is bridging care; the tragic piece to homelessness in New York City is that more shelters are needed to accommodate the needs of the people who don’t have access to affordable housing,” Olasin contends. “But with EHRs, we can work with health homes to provide bridging services to the next provider of care. So if someone is fortunate and leaves the shelter, we can connect [that person] with a health home and provide the medical information to the next person who is giving the care, with the [permission] releases that are obviously needed,” she says.

What’s more, through the use of the portal, the patient can have his or her own access with complete portability, as Care for the Homeless “web-enables” the population since 80 percent of individuals in homeless shelters have smartphones, explains Olasin. And once the organization’s mobile app gets up-and-running, she adds, the patients “will have access and portability to their health data that was provided during a period of their life when they were in a fragmented situation. And that’s incredibly valuable,” she says.

To this end, Olasin says that using the app could give patients the ability to make appointments with doctors and potentially use the mobile health service for telemedicine encounters. But she notes that one key issue is that these phones are in-and-out of operation for many homeless people who can’t pay their phone bills. “That’s a new type of barrier to care,” Olasin admits.

Partnering with MAeHC

To pursue its PCMH recognition, Care for the Homeless turned to MAeHC to provide strategic guidance and project management support. MAeHC’s experts worked hand-in-hand with the organization’s staff to help refine workflows, optimize and configure IT systems, identify patients for care management services, work with key staff in building care plans and workflows for high-risk patients, and enhance coordination of care with outside services such as hospitals and specialists, according MAeHC officials.

Olasin says that the PCMH process has allowed Care for the Homeless to turn the EHR into “a real tool,” in that it’s not only working for population-aggregate data collection for contracting use, but also on a specific basis for each patient. This way, says Olasin, “You can most effectively do care planning when you have a finite time period to work with them. But also, you can put the EHR in patients’ hands. Even if they don’t have a smartphone, maybe they can get to the library and once they are web-enabled, they are able to get to their EHR. The portal is something our population has found unique and surprising in their experience, and it’s not something that has been actively promoted before,” she says.

Importantly, Olasin points out that in addition to being medically disenfranchised, the homeless population are also socially disenfranchised. She explains that while a person might have become homeless in Queens or Brooklyn, he or she might have gone through an assessment in the Bronx and be in a shelter that isn’t close to where his or her children go to school, and where he or she has had prior medical and dental care. As such, with its on-site services, she believes that Care for the Homeless has been able to engender a type of facility in which “people want to know your name as opposed to you being out of many social loops for connectivity.”

Olasin further notes that social determinants of health have not always been addressed in the medical record, and therefore, the ability to effectively coordinate care has been limited. But she says that Care for the Homeless is working with its EHR vendor to integrate such documents, and there is protocol called a ‘prepare’ document, that as part of the patient intake, takes a review of the protocol for responding to and assessing patients’ access, risks and experiences.

“This is a social determinants of health intake tool that has been validated and that lets you stratify the degree of the risk of individuals coming into the system, in addition to the demographic information that is used.” The plan is for all of this together to go into a dashboard for relative risk stratification of the population being cared for, and then be added to the EHR, she says. “We’re starting to use this at the pre-visit planning piece, and [believe] that it will contribute significantly to the documentation of the complexity of patient care,” Olasin says.

This process will also allow clinicians and other medical folks to see what’s being done on the supportive service side of care, and vice versa. “This isn’t a concept that has been generally used in medicine. We always talk about the patient-provider relationship that’s driven from the patient as the person, but there is a mass customization where you want to be able to provide the optimal recommendations consistently across the board to everyone on an individual basis. And that has become a reality due to the effective application of EHR tools,” she says.

In the end, Olasin notes how the homeless population has not always benefited from getting the best in care, so “effectively leveraging technology so that you can have the best in both high-tech and high-touch for the optimal patient personal experience is what we are aiming for. And that’s really unique in this population,” she says.

Sponsored Recommendations

Clinical Evaluation: An AI Assistant for Primary Care

The AAFP's clinical evaluation offers a detailed analysis of how an innovative AI solution can help relieve physicians' administrative burden and aid them in improving health ...

From Chaos to Clarity: How AI Is Making Sense of Clinical Documentation

From Chaos to Clarity dives deep into how AI Is making sense of disorganized patient data and turning it into evidence-based diagnosis suggestions that physicians can trust, leading...

Bridging the Health Plan/Provider Gap: Data-Driven Collaboration for a Value-Based Future

Download the findings report to understand the current perspective of provider and health plan leaders’ shift to value-based care—with a focus on the gaps holding them back and...

Exploring the future of healthcare with Advanced Practice Providers

Discover how Advanced Practice Providers are transforming healthcare: boosting efficiency, cutting wait times and enhancing patient care through strategic integration and digital...