Health Care Utilization and Costs Among Public Housing Residents and the Homeless in Richmond, VA

BACKGROUND:   A small number of patients in the U.S. accounts for a large percentage of healthcare costs, with just 5% of Americans accounting for nearly 50% of costs (Kaiser Family Foundation). The ability to identify patients who are heavy utilizers of a hospital system is crucial so that targeted intervention and follow-up programs can be put in place to address their needs. The purpose of the current study was to 1) identify the health care hot spots in the Greater Richmond area with the highest utilization and costs and 2) describe the demographic, clinical and social profiles of patients in these hot spots and their patterns of health care utilization.

METHODS:   All payer claims data from one hospital system (Virginia Commonwealth University) during fiscal year 2009-13 was geocoded at the census block group level. Maps were created that presented cost and utilization data for inpatient stays, emergency department (ED) visits, and total cost of care. Based on hot spots found in these initial maps, additional analysis were performed for the homeless (n=737) and public housing residents (n=3,694) to identify the most prevalent conditions using Charlson Comorbidity Index among these two populations.

RESULTS:   Cost and utilization were concentrated in census block groups containing public housing. In this sample, adult public housing residents were primarily black (97%), female (73% of adults) and of child-bearing age (median age 34 among adults). The most prevalent conditions among public housing residents were mental health (28%), hypertension (22%) and COPD (18%), asthma (14%) and diabetes (13%). Over half (53%) had more than one condition. The homeless in this sample were predominantly black (57%), male (66%), 45 years and older (59%), and uninsured (56%). The most prevalent conditions among the homeless were mental health issues (67%), hypertension (33%), and drug/alcohol abuse (33%). Comorbidities were present in 82% of the homeless population. For both populations inpatient stays were the biggest driver of costs, accounting for 56% of housing and 74% of homeless patients’ total costs.

CONCLUSIONS:   Mental health is a potential focus area in both the public housing and homeless populations. Substance abuse also a major issue among the homeless. Four chronic medical diseases accounted for more than half of costs for public housing residents. Next steps include engaging community residents to identify strategies to reduce overutilization and exploring community-partnered interventions to improve health for individuals with mental illness and substance abuse.