Outreach to homeless needed to cut ER costs

The casualty count in Hawaii’s homelessness crisis continues to climb, and so do the costs.

Health care costs are among the biggest strains the fraying social safety net is unable to withstand.

In large part, the brunt is being borne by the private hospitals, but those costs are passed through to everyone in the form of higher bills and taxpayer assistance periodically sought to cover unreimbursed expenses.

Despite increased spending on Medicaid under the Affordable Care Act, some of the most frequent users of the system can’t pay the bills, even with whatever insurance coverage they have.

Such costs are what decisionmakers need to keep in mind when weighing the importance of housing policy. Getting people off the street, and keeping more people from falling into homelessness by addressing the need for low-income housing, is the only cure for this social ailment.

In the meantime, there are short-term solutions, and private hospitals, as well as the nonprofit social service sector, are heading in the right direction.

Among the institutions in the thick of it is The Queen’s Medical Center, whose emergency room providers see homeless patients on a regular basis.

Star-Advertiser writer Kristen Consillio chronicled the experience of Alexander Akuna, whose hospital stays have amounted to about 18 months. Akuna suffered from multiple chronic diseases, conditions arising from drug abuse, malnutrition and the stress of living on the streets.

If he is like typical patients with significant health care needs, costs for that care can add up to as much as $1 million.

There are thousands like him, although the biggest costs are incurred by a relatively select group. The city’s Emergency Medical Services agency reports that the top user of EMS summoned an ambulance, astoundingly, 157 times this year.

As for the hospitals, their officials are seeing rapidly rising costs. According to research by the Hawaii Health Information Corp., Queen’s cared for homeless patients 10,126 times in 2015, producing gross charges of $89.3 million. Those total charges are usually much higher than what is covered by insurance, and homeless patients can’t pay the difference.

Hospital administrations are wisely implementing their own programs to mitigate the problem. The approach at Queen’s is to identify the top 25 visitors — who racked up 1,514 visits and gross billings of $12 million — and provide them with preventive services and follow-up care outside the hospital.

Sheltering and social service agencies such as the Institute for Human Services often gets the referrals from hospitals and also are instituting stopgap measures. For example, IHS opened Tutu Bert’s House this year, a residence to give respite to the homeless who are recovering from hospitalization.

This model should be replicated, because it can reduce the rate of readmissions of patients discharged to the harsh environment of the streets.

The problem is clearly trending upward. IHS spokesman Kimo Carvalho said compared to 2012, when 434 homeless were referred from hospitals to the shelter, that number jumped to 735 in 2014 and hit 639 last year.

IHS and the University of Hawaii School of Social Work are doing a study, to conclude at year’s end, calculating the total financial burden homelessness puts on society. In addition to health care, the study will encompass the toll on public safety, the criminal justice system and other public agencies as well, Carvalho said.

That should add weight to the push to support more social outreach to the homeless population, both publicly and privately.

As an example: Project H.O.M.E. brings medical services to homeless encampments with the aim of treating illnesses at an earlier stage before hospitalization is warranted. This is a successful approach, with growth potential.

Of course, the Housing First initiatives at both state and city levels are key, in that the move to get people into stable housing with services is the most cost-effective way to keep the health of this population from deteriorating further.

Scott Morishige, the governor’s homelessness coordinator, listed Hale Mauliola on Sand Island and another project under construction in Iwilei, as two city-state partnerships that combine secure shelter with on-site services. That’s critical to those suffering from mental illness, substance abuse, physical ailments or, in many cases, some combination of all three.

Among the homeless, there is a sector that will continue to resist outreach, no matter how comprehensive it is.

Regardless, the drive to expand low-cost housing alternatives must continue to be seen as a worthy investment.

And especially for the expensive homelessness health care crisis that is looming, the preventive approach is clearly the right one.