Recuperative Care & COVID-19 in the Medicaid Population
Chloe Bakst, Kimberly Bower, MD, FAAHPM HMDC, Pooja C. Mittal, DO
Recuperative care, also known as medical respite care, provides acute and post-acute medical care for people experiencing homeless who longer require hospitalization but may need a safe place to recover. The National Health Care for the Homeless Council developed standards for Medical Respite programs that include the following:
• Safe and quality accommodations
• Environmental services
• Safe care transitions into medical respite from other settings
• High quality post-acute clinical care
• Care coordination and wrap-around support services
• Safe care transitions from medical respite to the community
• Quality improvement
Medical respite programs have been linked to lower rates of hospital readmission, and studies have shown that successful respite programs are linked to comprehensive case management and community partnerships.
Role of Medicaid and Medicaid Managed Care
Medicaid is the primary insurer for people experiencing homelessness. According to a report by the National Health Care for the Homeless Council, over half of medical respite programs report having three or more funding sources, with 18 percent of those surveyed identifying Medicaid/Medicare as a funding stream. In its annual survey of Medicaid managed care organizations (MCOs), the Institute for Medicaid Innovation found that 67 percent of Medicaid MCOs provided respite, palliative, or recuperative care for homeless or housing-insecure individuals.
Medicaid MCOs can finance medical respite programs in a variety of ways, including a per diem rate, a capitated per-member-per-month (PMPM) amount, a one-time case rate (e.g., paying a lump sum for each admission per time period regardless of length of stay), or a monthly payment to reserve a designated number of beds. They may also consider value-based payment approaches, such as outcomes-based financing, where payments may be tied to transition to permanent housing and decreased hospital or emergency department utilization, to support respite care for the Medicaid population. In a report to the Centers for Medicare & Medicaid Services as part of the Health Care Innovation Awards Round 2 (HCIA2) to develop a standardized model of care for medical respite programs and to assess program impact, health system costs and savings, and payment methodologies, found that most medical respite programs reduce at least one type of expensive medical utilization and likely reduce CMS expenditures.
Impact of COVID-19
COVID-19 has impacted medical respite programming across the nation. The Centers for Disease Control (CDC) have stated that people experiencing homelessness are at risk for COVID-19; at the same time, in response to public health guidelines, many homeless shelters have had to reduce service and restrict admittance. This puts those experiencing homeliness at even higher risk of illness. In a tool for developing an infection prevention and control protocol for homeless service settings, the CDC recommended providers facilitate links to respite care for people experiencing homelessness who were hospitalized but have since been discharged.
Response of Medicaid MCOs
Medicaid MCOs have recognized the importance of medical respite programs as part of their response to the COVID-19 crisis. In April 2020, United Healthcare Community and State released a white paper, Medicaid & Medicaid Managed Care: Financing Approaches for Medical Respite Care that included a list of action steps for Medicaid MCOs to consider in order to support the financing of medical respite programs.
As part of their strategy to address continuity of services for people experiencing homelessness or who are on the verge of homelessness, LA Care increased available beds at recuperative care sites for people experiencing homelessness after discharge from the hospital for short-term recuperation. AmeriHealth Caritas DC worked to support access to medications, home health services, transportation and other resources which supported health maintenance and continuity of care for people experiencing homelessness. They also provided education to shelter staff regarding Medicaid benefits and availability of care management staff to assist with coordinating access to care. Health plans such as HealthNet are working on transitioning members from respite programs to other services, such as in-home services and supports and/or permanent supportive housing. Recuperative care may represent an opportunity to leverage transitional housing into identifying needs for other services that members may be experiencing.
Homelessness among working-age adults caused by the current recession is projected to peak in 2023, adding 603,000 working-age adults to those already without a place of their own to sleep in the United States. This has serious implications for the Medicaid population and Medicaid stakeholders, including Medicaid managed care organizations. Future research should explore how Medicaid MCOs may have a unique impact in addressing the health needs of people experiencing homelessness, including providing critical respite care.