​Answers to questions submitted during and after the October 23, 2017 webinar appear below. Responses Answers were provided by presenters Stephen Leffler and Penrose Jackson from the University of Vermont Medical Center.

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What was the source(s) of funding for the 2,691 bed nights?

Our case management team saw that overstays were a big problem for us, and we needed to figure out a way to discharge people safely who no longer needed to be in the hospital. We are the only tertiary care center in VT, so when we have beds that we can’t use to accept transfers, that’s a real issue for our region. In the first year, we decided to purchase a certain number of bed nights in order to make the pro forma on the motel work, and as if by magic, it did. They estimated pretty accurately, pretty close to what we ended up using. This allowed us to keep patients in a structured environment, but not in a hospital bed when they no longer needed one medically. Getting those people out of the hospital and using those beds for patients who need to be transferred in made good sense all the way around. We took those dollars out of operating dollars, and we purchased those nights for the motel. We were confident that those nights would pay for themselves by bringing in other patients that we might otherwise have had to decline to accept. When we discharge people from the hospital to Harbor view, if they need resources to afford housing, we give them a voucher. They present that voucher to the person running Harbor Place for a specified number of nights, and Harbor Place charges the medical center of the guaranteed nights that we have already purchased.

Vermont has a very complicated model of hospital budgets. We are capped for patient revenue. If the hospital exceeds that cap, then we have to pay the money back to the state. In 2015, with the hospital very busy, and we exceeded our revenue cap. Because we were working toward a capitation model, we asked our regulator to let us use some of those excess revenue dollars in our community to let us get ready for capitation. So we were allowed to put some dollars into homelessness, some into mental health, and some into substance abuse. So those dollars came from our patient revenue overage in 2015. When we were given the opportunity to address this unexpected revenue, we already knew from our experience, our community health needs assessments, and our relationships with so many community partners where we could make valuable investments to start to move other needles.

I wouldn’t say we have an unrestricted pool. We are on a journey towards capitation – for 80% of our revenue to be under capitation. Right now we are at 30%. When you get to 25-30%, that’s when cost avoidance becomes critical, because that is where you start to make your margin. For many years, we have been investing a small portion of our margin – about $1 million a year, or about 2.5% – in our community through the CHNA and the Community Health Investment Committee’s discretion. These have been targeted investments. With capitation, more dollars will become available as well.

No, we don’t have CHWs yet. There are actually very few in the state. I put them in the budget each year and keep trying. However, the case managers that work out of the Safe Harbor Clinic could fill that role if we want to define it that way. Everything from food and clothing to maintaining shelter, and they get them referred into appropriate mental health and other medical needs. So we are more than meeting the work a CHW would do through other supports.

Basically our case managers know who is going to be difficult to place because of their care needs, or poor insurance, or a long commute to the hospital. So a recent example, we’ve had people discharged to Harbor Place who live four hours from the hospital. They have so many recurring follow-up appointments, but they are not going to be able to travel back and forth, and they do not have resources to stay in a hotel. So we put them in Harbor Place for 8-9 days until their appointments are done. We’ve had people go there who couldn’t make it upstairs in their housing. We’ve had a number of homeless people go there while convalescing, and while they are there the case managers try to get them into longer term housing. For people coming from the hospital, the decision is made by the case managers in consultation with their medical providers. For Beacon and Bel Aire, it’s done in partnership with the community partners who know who the most needy patients are – those with the greatest potential medical needs based on the CHNA already done.

A lot of providers talk about having patients show up at the hospital with social issues that make it hard to discharge, even if they do not need hospitalization. It’s common everywhere. Sometimes hospitals will try to move a patient to another medical center to open up a bed. Some people call that “patient dumping.” There are no rules or regulations around that because if the patient is felt to have a health issue, and you have capacity to care for them, because of EMTALA, you have to accept them. In Vermont we all know each other, the CMOs meet regularly. So if someone was doing that, we have a relationship that would allow us to have a discussion. If we’ve accepted someone at the academic medical center, and we determine they no longer need to be here, I will call my colleagues at the other medical centers, and typically they will take them back.

When we did our homelessness study, 70% of the people had multiple chronic health conditions, and 60% had mental health that was contributing to their homelessness. Something around 90% had a traumatic brain injury. The vulnerability index measured this in that study. We did not identify diabetes in our CHNA, though we did talk about access to healthy food as a kind of side door into addressing diabetes. There is significant casework that includes behavioral health and other physical health care needs. These are complicated cases. The costs of their inpatient and emergency healthcare has gone down. We believe this is likely due in part to their increased use of primary and preventive care.

The 19 apartments are permanent; they can live there for the rest of their lives. There have been a couple or people who were asked to leave because of some behavioral issues, I believe there was some domestic abuse in one case. They are given as many supports as they could possibly be given so that they will have successful housing. I also want to note that I have heard (maybe it’s an urban legend) that a man and women who were at Beacon Apartments are now in permanent housing as a couple in Bel Aire.

For the permanent housing, it has been the risk score. For the short-term housing it’s really people whose current housing (or lack of housing) doesn’t meet their medical needs. Bel Aire is still new, but those are people who have been stuck in the hospital for a long period of time, and the trespite beds at Bel Aire will allow them to get their care out of the hospital.

There is a little bit of “NIMBYism” that happens everywhere. There were some challenges in Harbor Place. Some people in the area felt it was no longer a hotel, even though it is still registered as a hotel and people only stay an average of five nights. So they tried to get it shut down based on zoning. We went in front of the zoning board and explain what we were doing, why we were doing it, and why we saw it as purchasing nights. There are some people who stay there who do not have medical issues because we don’t purchase all of the nights for all of the rooms. Because it’s a hotel there is a limit on how long people can stay there. At Bel Aire we set our own limit so people would get back to better health and then leave so it would have some turnover. It is a motel and people are coming and going and there can be some challenges. With Beacon Apartments it was handled somewhat differently in terms of preparing to open the facility. The neighbors there actually welcomed people because they thought it would be more consistently managed and overseen than it had been before. There were some issues early on with the police feeling that they were being called to the Harbor building. But subsequently they have really worked it out. They go and meet with them with no walky-talkies and no weapons, just neighborhood watch officer friendly type of approach, and it has really improved things. They see it as a partnership in keeping everyone safe at the apartment building and keeping the neighborhood safe. We have gotten smarter as we’ve gone along.

I have a little vignette. About year ago I went to a United Way meeting and talked to them about the project and showed them our video, which is really quite moving. One of the people leaned back in his chair and said “I drive by that place every morning and I have watched those people get healthier. I see them get the bus, I see them on their bike, and their color is better, their posture is better, and I’ve watched them get healthier.” He saw it in such high resolution that he could comment on it. The video I mentioned is available online.

The program is really just getting started. We will continue to assess the needs, but for now having extended stay is a response to the needs we are seeing.

We are just continuing to chip away at this problem. As long as the program continues to pay for itself in reduced hospital costs – usually unreimbursed care – we will keep it up.

Housing sites we’ve talked about today are all on the bus routes. We do provide bus vouchers for them.

We built on relationships that had been in place for decades. We have a really rich tradition here of working with partner organizations on a wide variety of things dating back to the 1980’s. We already knew who we could work with. Champlain Housing Trust runs a very effective program and has a huge commitment to getting people into housing. The partners were extremely happy to have us come to the table. In 2013 we weren’t really able to jump in. But once we said we wanted to be a part of it, they welcomed us.

For the five permanent apartments, they do sign a lease. For the medical respite ones they do not.

We partnered with the department for children and families, which along with the department of health, is housed in the department of human services. It’s been more challenging with Medicaid because some of the services offered there do not quality for reimbursement under Medicaid.

The bit of genius with ours is that we were looking at what changed from a medical perspective. We were able to demonstrate rather quickly what the impact on cost would be of a short stay. Count whatever you can count. With other social determinants, the rewards would be further out. Track your results, because if you can show a return on investment that opens up lots of opportunities to create more programs.

I think it’s the CHNA and 30 years of working with the same partners. It’s knowing each other and talking to each other, which is easy here. We’re good at acknowledging our limitations, and finding what we can do to supplement what one another does.

When the 19 Beacon slots are full do you anticipate still need more permanent subsidized housing (PSH) units. Are you looking to expand access to PSH?

I know the Champlain Housing trust is looking at another site. We have a commitment to make long-term homelessness only a memory. It’s aspirational, and we have a ways to go. But we have also reduced homelessness 30% in the past three years.

The data speak for themselves. This is a job that will never be done, but we have made progress.

Yes, they do. They work with them on any needs they have whether it be getting a primary care doctor, or Medicaid, or transportation, or treatment for their other chronic conditions.