Containing Health Care Costs By Getting Homeless People Into Housing And Out Of The ER

May 11, 2018

On a mild spring day, 47-year-old Tom Lefevre stood on his apartment’s back porch, which overlooks a quiet, wooded area in the borough of Bellevue, just outside Pittsburgh along the Ohio River. 

Relaxed and smiling, Lefevre leaned against the porch railing for a few moments listening to the chirping of birds before gesturing towards the nearby tree line.

“I love sitting out here in the morning … and watching the animals come through," Lefevre said.
"I see deer come through, raccoons, coyotes … rabbits. It’s like having your own menagerie in your backyard.”

Leaning against the porch’s wooden railing, Lefevre looked very much at home. But he didn’t always have a roof over his head.

About 15 years ago, while working as an auto mechanic, he suffered a back injury that left him disabled and unable to work. Eventually, he became homeless.

“I had lost everything, in and out of homeless shelters, living on the street,” Lefevre said.

He also developed arthritis and high blood pressure along with his disability, and like many homeless people, when Lefevre needed care, he usually ended up at the emergency room, he described himself as “bouncing in and out, a lot.”

During one of those ER visits at UPMC Mercy about eight years ago, Lefevre finally decided enough was enough.

“I told them right there at the hospital, I need help and I ain’t going anywhere till I get it,” Lefevre said.

By the time he was discharged, Lefevre was on a path that would land him in an apartment of his own, through a program called Cultivating Health for Success, administered by UPMC Health Plan.

According to UPMC Health Plan’s president of government programs, John Lovelace, Cultivating Health for Success is geared towards people like Lefevre: homeless, suffering from chronic conditions and with a history of unplanned care.

“Things like emergency room visits, re-admissions, crisis services, detoxes, lots of services that indicate people aren’t very well attached to the healthcare system,” said Lovelace. “So their chronic conditions are not being managed other than in sort of acute, spotty fashion.”

The program serves 25 patients at any given point and is run in partnership with the non-profit Community Human Services. In addition to housing vouchers, patients get one-on-one help from case managers and nurses.

Case managers help participants find a place to live and continue to assist them with basic tasks of household maintenance like paying rent, taking out the trash and dealing with landlords.

Nurses make home visits to check up on the patients and ensure they’re scheduling doctor’s appointments and keeping up with their medications.

Lefevre said he now regularly sees both a primary care physician and a specialist for his back.

“I’m just so thankful to have the whole team on my side,” said Lefevre.

Not only are those routine doctor’s visits better than erratic ER visits when it comes to managing the chronic conditions, but they also tend to be cheaper, said Lovelace.

In 2013, the National Institutes of Health estimated the average cost of an ER visit to be about $1,200. Numbers from Blue Cross Blue Shield put the typical cost of a visit to the doctor’s office in the range of $130 to $240.

Such an approach -- coordinating housing for homeless people as a way to curtail health care costs -- is gaining popularity across the country, said Eric Roberts, a health economist at the University of Pittsburgh.

People who face housing instability often come to our health care system with high costs and high needs for care,” said Roberts. “And so, the thought is, can we take some of that vast sum of money we spent on health care and divert it more meaningfully and more efficiently outside the system, in ways that address the root causes?”

From 2010 to 2015, the overall cost of care for patients housed through Cultivating Health for Success dropped about $6,400 per year.

UPMC does spend about $6,000 per year per patient to run the program. The federal government kicks in around $6,900 in housing vouchers for each patient annually. 

Even so, Lovelace said the real savings are in the long term, because patients are living in homes instead of on the street and learning to manage their conditions instead of getting sicker for lack of care

“Housing is sort of the nexus by which you’re connected to economic opportunities, to health-promoting opportunities. And has a profound impact on your current health and also your likelihood of future well-being," said Roberts.

Right now, Cultivating Health for Success is only open to patients who meet a narrow standard of chronic homelessness, as defined by HUD.

Lovelace said UPMC Health Plan wants to offer similar services to people who aren’t technically homeless by that definition, but who nonetheless struggle with housing — for example, someone bouncing between relatives' couches and homeless shelters, or youth aging out of the foster care system. That intervention, he said, could catch these people before they end up on the street.

WESA's Bridges to Health covers the well-being of Pennsylvanians and is funded by the Jewish Healthcare Foundation.