1. Chicago Housing for Health Partnership: Findings of a Randomized Controlled Trial of Supportive Housing and Case Management for Homeless Adults with Chronic Medical Illness Laura Sadowski and Romina Kee, Collaborative Research Unit Cook County Hospital (Stroger) and David Buchanan, Erie Family Health, Chicago

2. Primary Research questions Today’s presentation are the final outcomes that answer the research questions… Among homeless adults with chronic medical illness … 1)Will CHHP lower the use of costly medical services? 2)Will CHHP increase housing stability at 18 months? Selected secondary findings presented: Nursing home, HIV

3. What did we want to learn? Among the homeless with chronic medical illness… 1)Will CHHP lower the use of costly medical services? and if so, by how much? and do so without any harmful health effects… 2)Will they achieve stable housing at 18 months?

4. How did we get the information (data)? Interviews at baseline (enrolled in hospital) Follow-up interviews at 1,3,6,9,12, and 18 m Hospital electronic records (study hospitals) Medical records (outside hospitals, 66 hospitals) Internet data bases (incarceration, deaths)

5. Interviews Face-to-face Baseline  2 hrs, Follow-up  35 mins Content: Tracking and Housing Quality of Life (ACTG-SF21) Alcohol and Drug use (ASI) Mental Health Symptoms (Prime MD) Health Service Use (HIV cost study modules) Compensation: $20/interview

6. Who could participate in this study? Inpatients referred to Social work for discharge planning at two hospitals. Social workers referred those who were homeless to research team Monday-Friday

7. Who could participate in this study? Inpatients referred to Social work for discharge planning at two hospitals. Social workers referred those who were homeless to research team Monday-Friday Who was eligible? (verified by research staff) – 18+ yrs of age, English or spanish speaking – Expected to be in hospital 24+ hours – 1 or more chronic medical illness (medical record) – Able to self care upon discharge (physician assess) – Lack of stable housing 30d prior to hospitalization – Informed consent

8. Who was in the study? 604 referrals from hospital social workers 455 eligible referrals 48 refused 407 participated (89% of eligible) 2 withdrew (Usual Care) baseline sample of 407, analysis sample of 405

9. Who ended up in the study? 76% men 78% AA, 9% Caucasian, 8% Latino 54% graduated from High school Age 21-82 years of age, (median=46 yrs) 54% never married 9% veterans

10. Who ended up in the study? 76% men 78% AA, 9% Caucasian, 8% Latino 54% graduated from High school Age 21-82 years of age, (median=46 yrs) 54% never married 9% veterans 55% no insurance, 37% Medicaid, 8% Medicare, 1% HMO/PPO 36% HIV + 32% High Blood Pressure 13% Diabetes

11. Who ended up in this study? Housing before study (past 30 d): Family/Friends: 50% Shelters: 43% Streets: 27%

12. Spectrum of Homeless Duration Duration homeless: 26% less than 1 y 58% more than 2 y Median: 30 m Median for HIV+: 28 m Maximum: 440 m

13. Hospitalizations and ER visits at Study Hospitals during 12 months before study Usual CareCHHP Hospitalizations0.891.24p<.05 ER visits2.522.23 Intervention group had.35 more prior hospitalizations than usual care at the study hospitals in the year prior to the study Data Source: Electronic Medical Records, JAMA Table 1 Hospitalization at Study Hospital in prior 12 m: 53% None ER visits at Study hospital in prior 12 m: 41% None

14. Spectrum of mental health and substance use Mental health symptoms at enrolling hospitalization (past 4 w) : 40% major depression 23% other depression 28% anxiety Substance use (past 30 d) : 41% alcohol (to intoxication) 45% cocaine 28% heroin 59% any drug

15. Follow-up at 18 months Interviews at 18 months: 90% CHHP program 73% Usual care Supplemental tracking: “real time” tracking in study hospitals/ERs using electronic medical records and social workers, tracked appointments and presence in ER or hospitals

16. Unadjusted and Adjusted Results Example: Multiple factors, including CHHP, influences an outcome – e.g., hospitalization Unadjusted: # of hospitalizations / # of people who could have experienced an event Adjusting for other factors: Remove the influence of other factors on hospitalizations, so that the independent effect of CHHP can be determined. Requires collecting data on all the factors. Examples: Age, HIV, Substance use, prior hospital use Presentation today – unadjusted – simpler. Note: After adjusting for, the differences between the 2 groups became statistically significant (Table 3 in JAMA article)

17. Study Results: Hospitalizations CHHPUsual Care Avg # hospitalizations, annual:1.92.4 Avg length of stay, annual:8.7 d11.4 d Not statistically significant unadjusted (JAMA, 2009, Table 2).

18. Study Results: ER Visits CHHPUsual Care Avg # ER visits annual:2.613.77 Not statistically significant, JAMA, 2009; Table 2 Costs: Data not ready for use in terms of cost. Adjust for those who did not receive ER care (LWBS).

19. Preliminary Study Results: Mortality, 12%+ CHHPUsual Care Mortality:2523 Mortality in HIV+:13 9 No statistical difference, Detection Bias, Data Collection continues

20. Nursing Homes: Housing or Health Service? 94 participants (23%) stayed in 62 Nursing Homes Duration: 48% temporary, short term – 23 stayed < 30d – 13 stayed 1-2 m – 9 stayed 2-3m Limitations: Self report, Differential Follow-up bias, Necessity of stay unknown, Added late – at 9 m

21. Study Results: Nursing Homes An unanticipated, important outcome 18-month Follow-up: CHHPUsual Care Nursing home (at least once) :19%27% Nursing home days:5,909 d10,044 d Difference is NOT statistically significant, yet important

22. Such a large difference in NH days, why isn’t it statistically significant? Majority of BOTH groups had no nursing home stays CHHP Usual Care No NH stays81%73% NH stays19%27%

23. Graphs of Nursing Home days by group

24. Quality of Life: Physical and Mental Health Measures mental health and physical health functioning Health change: 18 month score – baseline score. CHHPUsual Care Mental Health+14.7+14.4 Physical Health+ 7.7+ 6.5 Both groups improved similarly (even after adjusting) No statistically important difference Scores transformed to a 100 point scale

25. Additional Findings for HIV: preliminary ER visits and Hospitals Stable Housing at 18 months

26. HIV subgroup findings: ER visits and Hospital days CHHPUsual Care n=75 n=71 Emergency Room Visits, annual Avg # hospitalizations, annual: Length of stay, annual: Unadjusted results

27. HIV subgroup: Where are they at 18 m? Ineligible for Stable Housing Dead 15% Nursing Home 7% Incarcerated 12% Residential CD treatment 3% Lost to follow-up15% Eligible for Stable Housing 48% of sample was available for stable housing Intervention 39 Usual Care 31

28. HIV subgroup: Where did you stay last night? CHHPUsual Care n=39n=31 Among eligible…. Stable housing (rental/public):66%13% Less stable (friend/relative):34%74% Unstable (street, vehicle, shelter): 013% Avg # housing changes: 2.1 3.4

29. Limitations Generalizability – to whom do our results apply? to men and women who lack stable housing (>30d), have a chronic medical illness, and ≥ 1 hospitalization in an urban setting Appropriateness of ER visits & NH days not assessed – use cautiously for any cost, health or housing implication…. Nursing Home and Housing Stability data relies on self report (unverified)

30. Conclusions At 18 months, offering the CHHP program to homeless men and women with chronic medical illness: Reduced ER visits by about 1.2 annually* Reduced hospital days by about 2.7 annually* Although findings were in the right direction and important magnitude, we did not achieve a statistically significant difference in… Quality of Life Incarceration (data not shown) Nursing home days Detection of mortality difference (pending)

31. Other Findings: Nursing Homes, HIV Nursing home stays were frequent (23%) and an important outcome with cost implications (>15K d). 48% of NH stays were short term <90d Among those with HIV, offering the CHHP program…. Add urgent health service use at 18m Add stable housing outcomes at 18m