H E A L T H C A R E S U P E R - U T I L I Z E R S Stephen Brown MSW LCSW PMP Director of Preventive Emergency Medicine University of Illinois Hospital & Health Sciences System Stephen Brown MSW LCSW: UI Health
W H A T I S A “ W I C K E D P R O B L E M ” The phrase was originally used in social sciences. A wicked problem is a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. It affects multiple players that may not be aware of the other. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems. The key to finding an answer is to acknowledge it is a complicated problem, and that no individual, organization, agency or governmental body can solve this by themselves Stephen Brown MSW LCSW: UI Health
W H E R E Y O U L I V E A F F E C T S H O W L O N G Y O U L I V E Your socioeconomic status affects your health Examples • Housing Status • Food Insecurity • Transportation • Mental Illness • Substance Abuse • Interpersonal Violence Third world countries with similar life expectancies to Washington Park Where you live, access to education, to employment, and other variables are called The Social Determinants of Health Stephen Brown MSW LCSW: UI Health
P O P U L A T I O N H E A L T H A minority of patients accumulate most of the cost & utilization In most states, 5% of Medicaid patients make up 48% of the cost a.k.a “Power Law Distribution” Stephen Brown MSW LCSW: UI Health
C O M O R B I D I T I E S a.k.a “Power Law Distribution” Stephen Brown MSW LCSW: UI Health
Extraordinary psychosocial / disease burden 72% have 3 or more chronic diseases Disease Psychosocial 80.0% 60% 73% 70.0% 50% 48% 60.0% 40% 51% 50.0% 48% 43% 40.0% 30% 38% 30.0% 20% 24% 21% 21% 15% 20.0% 13% 15% 11% 9% 10% 10.0% 4% 0.0% 0% M2S M2S Anxiety Substance Smoking Low Social No PCP Low Med % <= 8th Grade 0 Diseases 1 Chronic 2 Chronic 3 Chronic 4 Chronic 5 or More Depression Use Disorder Support Adherence homeless/top Reading Disease Diseases Diseases Diseases 50 Level Stephen Brown MSW LCSW: UI Health
High rates of mental illness & substance abuse % OF PSYCH DX BY NUMBER OF ANNUAL ED VISITS 1 22.15% 22356 4951 100.00% 2 35.32% 4553 1608 There is a 80% probability 3 44.72% 1592 712 that a patient who 86.09% 85.71% 84.17% 82.68% 81.82% accumulates 8 or more 4 52.04% 736 383 78.95% visits in the previous 12 75.31% 5 60.46% 306 185 months has either a 6 82.68% 127 105 Psych DX % of Total mental illness or a substance abuse disorder 7 84.17% 120 101 60.46% 8 75.31% 81 61 52.04% 9 81.82% 44 36 44.72% 10 78.95% 38 30 35.32% 11-20 86.09% 115 99 21-30 85.71% 21 18 22.15% 31 _ 100.00% 11 11 27.57% 30100 8300 Calendar Year 2014 1 2 3 4 5 6 7 8 9 10 11-20 21-30 31 _ 46,186 Visits 30,100 Unique Patients 8,300 Patients had a Psych Diagnosis (27.7%) Number of Annual ED Visits
H I G H R A T E S O F C O S T S & U T I L I Z A T I O N Hospitalization rate Annual Costs Annual # of hospitalizations Relative Costs by number of acute sites of care accessed
H E A L T H C A R E & H O M E L E S S N E S S Homelessness is virtually unrecognized in healthcare, yet this health-related social need carries risks as great as cancer or advanced cardiovascular disease
U I H E A L T H 68 Number of homeless identified via survey of ED and psychiatry staff in June 2015 - 20 had no encounters in the previous year - 48 had healthcare costs that 4.8x higher than our average patient 635 Found to date through labor-intensive chart audits source: UI Health EPIC Project Stephen Brown MSW LCSW: UI Health
U I H E A L T H E M E R G E N C Y D E P A R T M E N T F R E Q U E N T V I S I T O R S 45% …of the top 100 ED frequent visitors are homeless 20% ...of ED “super-utilizers” (~300 patients who have had 8+ visits in the previous year) 57% …of UI Health’s 600+ homeless (350) have had at least one ED visit within the previous 12 months source: UI Health EPIC Project Stephen Brown MSW LCSW: UI Health
W H A T D O W E M E A N B Y H O M E L E S S N E S S ? Three Typologies Both individuals (48%) and families (52%) who become homeless due to a housing, health care, or other financial 80% transitional crisis. They come into the shelter system and stay about three months and often move into housing. More individuals than families who regularly go in and out of shelters. 10% episodic They tend to be younger and leave shelters when they get income, or use shelters seasonally. Primarily individuals who have been homeless for a year or 10% chronic more, or four times in the last three years. They tend to be older with significant mental illness, substance abuse and many have a chronic medical condition(s). Stephen Brown MSW LCSW: UI Health
W H Y F O C U S O N T H E C H R O N I C A L L Y H O M E L E S S ? …yet account for nearly 80-90% of the Among all homeless, the chronically total cost of services to the entire homeless make up 10-20% of the population general population… We’ve found that chronically hom eless people, w ho are about 12% of the hom eless population, 86 m ake up 80% of the total 80 100% 100% governm ent costs spent, from % em ergency room visits to jail % tim e…. We are w asting a huge 75% 75% am ount of m oney in this country keeping these people hom eless.” 50% 50% 20 Jake Maguire, Director of % Communications for the 100,000 14% 25% 25% Homes Campaign 0% 0% Typical Typical Cost Prevalence Stephen Brown MSW LCSW: UI Health
A N E X P E N S I V E , F R A G M E N T E D D E F A C T O “ S Y S T E M ” $3,000 Without the stability of a place to live, $2,500 the homeless seek services in facilities $2,250 that are exceedingly more expensive $1,500 $1,185 $750 Per Diem $700 $57 $73 $125 $164 $0 Supportive Housing Nursing Home Emergency Room Hospital Public Facility Stephen Brown MSW LCSW: UI Health
S H O R T E R L I V E S Risk of Early Death The average American is expected to live to 78 years old The chronically homeless’ average life expectancy is 53 years old Stephen Brown MSW LCSW: UI Health
H E A L T H R I S K S 0.75 0.65 56% There are high rates of mental illness, 0.55 0.45 33% 0.35 substance abuse, HIV/AIDs & Domestic 23% 0.25 0.15 4% Violence 0.05 -0.05 Mental Illness Substance Abuse HIV/AIDS Domestic Violence Up to half of the chronically homeless may have a Traumatic Brain Injury (TBI) The chronically homeless have high rates of head, neck and breast cancers 60% of the chronically homeless that use cocaine & heroin have asthma or COPD 46% report at least one suicide attempt Stephen Brown MSW LCSW: UI Health
U I H E A L T H B E T T E R H E A L T H T H R O U G H H O U S I N G 3 …of the 27 referred into housing have died. (11.7%) …have had undiagnosed traumatic brain injury, 5 dementia or intellectual disability, and no family (18.5%) support. 6 …have head, neck or breast cancer. All are in (22.2%) advanced states and all have been out-of-care source: UI Health EPIC Project Stephen Brown MSW LCSW: UI Health
I T S C H E A P E R T O H O U S E T H E H O M E L E S S Programs in other cities have demonstrated it costs a third to a half to house the homeless rather than having them remain homeless. $60,000 $60,000 $45,000 Annual Costs $30,000 $18,000 $15,000 $0 Supportive Housing Homeless Housing Stephen Brown MSW LCSW: UI Health
P A Y M E N T I S A W I C K E D P R O B L E M Management Prevention $150m Who? ambulance • Bankers social service • Finance psychiatric care $75m shelter ambulance police How do we get from social service psychiatric care here..to here shelter healthcare police healthcare HUD HUD before after Stephen Brown MSW LCSW: UI Health
C O U L D W E H A V E S E E N I T C O M I N G ? …If we could connect public sector data silos Chronic Homelessness Oppositional Defiant Disorder Incarceration Foster Care Episodic Homelessness Chronic Parents with Gang Inebriation substance Involvement abuse or mental Criminal Activity Early Death illness Drop-out Non-related adult 50x Truancy risk of abuse Lead Poisoning 0-2 2-5 6-12 13-25 26-40 40+ Many chronically homeless have risk factors that originate in childhood, yet develop into issues that span a lifetime, Stephen Brown MSW LCSW: UI Health
T H E F O G I S L I F T I N G 4 of 11 individuals shot 85% of residents in 40% of foster children that age out of the by police were lead PGM are chronic DCFS system are poisoned in youth inebriates (10+ years) homeless in their 20s. 1 of top 5 reasons for truancy in Washington 70% of those with a Park is Parental Mental personality disorder Illness or Substance suffered trauma as Abuse children Most frequent hotspots for 911 dispatches for psychiatric crises are the end of CTA EL lines
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