DNP 711 Module 7 White Paper Example

A Place to Heal: A White Paper on Medical Respite Care for Arizonans Leaving the Hospital Without a Home

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

DNP 711: Healthcare Policy and Innovation

Instructor Name

Month Day, Year

A Place to Heal: A White Paper on Medical Respite Care for Arizonans Leaving the Hospital Without a Home

Executive Summary

Every week, Arizona hospitals discharge patients who are medically ready to leave but have no safe place to recover. Many return sicker. Medical respite programs give such patients a place between the ward and the sidewalk: a bed, meals and a nurse who checks on them. Research shows fewer hospital days and readmissions among patients who receive respite care, though most studies are observational. This paper recommends a two-year, 60-bed pilot in Maricopa and Pima counties, with the state and the Medicaid health plans splitting the cost, with program standards, an independent evaluation and a decision point on a Medicaid waiver amendment.

Background

People experiencing homelessness have higher rates of chronic disease, injury and infection than housed adults, and they are hospitalized more often. When they are ready for discharge, many still need care that requires rest, hygiene and a stable place to store medications. Shelters are rarely able to accept people with wounds, drains or mobility limits, and nursing facilities seldom take patients without a payer for a long stay. The result is a cycle familiar to every safety-net case manager: discharge, deterioration, readmission.

Medical respite programs break that cycle by providing a bed, meals, nursing oversight, medication support, transportation to follow-up visits and help finding housing, usually for a few weeks. Programs range from a few beds inside a shelter to freestanding facilities with clinical staff on site.

Stakeholders

Hospitals, AHCCCS, Medicaid health plans, respite operators, the legislature and its budget staff, local governments, neighbors of proposed sites and people with lived experience of homelessness all have a stake (see Blog 2). Hospitals and plans have the clearest financial interest in fewer readmissions. AHCCCS and the legislature hold the power to fund a program. Those who sleep in respite beds carry the greatest stake yet hold almost no power over the program, so the proposal gives them a paid advisory group.

Policy Mechanisms

Three routes can fund respite care: a Section 1115 waiver amendment submitted by AHCCCS to the Centers for Medicare and Medicaid Services, a state appropriation through the annual budget, and requirements or incentives in AHCCCS contracts with health plans. A waiver offers durable federal matching funds but takes time and depends on shifting federal priorities. An appropriation and contract incentives can move within a year. This proposal uses the faster routes to build Arizona evidence for a later waiver.

Evidence

The evidence supports testing respite care but does not prove that a program in Arizona will save money. Savings depend on who is enrolled, how long they stay and what happens when they leave. A well-measured pilot is the honest next step.

Proposed Pilot

Scope: two years and 60 beds in all, two thirds of them in the Phoenix area and the remaining third in Tucson, with nonprofit operators chosen through competitive bids.

Eligibility: adults experiencing homelessness, discharged from an Arizona hospital, with an acute medical need that can be managed outside the hospital, such as wound care, completion of antibiotics or recovery after surgery, and able to manage basic self-care with support.

Services: a private or shared bed with storage; three meals; daily nursing assessment; medication support and safe storage; transportation to follow-up appointments; behavioral health and substance use referral; a housing navigator from the first day.

Program standards: each site would meet national standards for medical respite care in staffing, clinical oversight, discharge planning and safety, verified before funding and audited yearly. Rules would be designed with the lived-experience advisory group to avoid barriers such as daytime lockouts that make recovery impossible.

Cost Model

Funding: $4.4 million from a state appropriation to AHCCCS and $4.4 million from Medicaid health plans through contract incentives tied to readmission measures. The evaluation will compare these costs with hospital and emergency costs for a matched group of patients discharged without respite, so that savings are measured rather than assumed.

Evaluation Plan

Primary outcome: hospital days in the 12 months after discharge. Secondary outcomes: 30- and 90-day readmissions, emergency visits, completion of treatment, whether each person leaves for a housing placement, and the net cost of each stay. Comparison: patients meeting the same criteria at hospitals outside the pilot area or discharged when beds are full, matched on diagnosis, age and prior use. Reports at 12 and 24 months will go to the legislature, AHCCCS and the public.

Equity Safeguards

People experiencing homelessness in Arizona are disproportionately Black and Native American, and many are older adults with disabilities. The pilot would track enrollment and outcomes by race, ethnicity, age and disability; include tribal health partners in planning so that Native patients discharged from urban hospitals can access beds; and pay advisory group members for their time. Dawes (2020) notes that health equity depends on who shapes policy as well as who benefits from it.

Advocacy Strategy

Following advice from my policymaker interview, the campaign would open with one story and one number, meet with budget staff before the session, and build a coalition that includes hospitals, health plans, county sheriffs and faith groups. Kingdon (2011) describes how solutions that are ready when a window opens are more likely to be adopted; this paper and its cost model are intended to make the pilot ready for the next budget cycle.

Recommendations

1. Legislature: appropriate $4.4 million over two years for a medical respite pilot administered by AHCCCS.

2. AHCCCS: add contract incentives for health plans to fund matching respite services and require participation in the evaluation.

3. Hospitals: share discharge and readmission data with the evaluator and designate respite liaisons in case management.

4. All partners: revisit a Section 1115 waiver amendment at the 24-month report if results support it.

Conclusion

Arizona already pays for the cycle of discharge and readmission, in hospital costs and in human suffering. A modest, well-measured pilot would test whether a place to heal can break that cycle and would give the state its own evidence for deciding what comes next.

References

Buchanan, D., Doblin, B., Sai, T., & Garcia, P. (2006). The effects of respite care for homeless patients: A cohort study. American Journal of Public Health, 96(7), 1278-1281. https://doi.org/10.2105/AJPH.2005.067850

Dawes, D. E. (2020). The political determinants of health. Johns Hopkins University Press.

Doran, K. M., Ragins, K. T., Gross, C. P., & Zerger, S. (2013). Medical respite programs for homeless patients: A systematic review. Journal of Health Care for the Poor and Underserved, 24(2), 499-524. https://doi.org/10.1353/hpu.2013.0053

Kingdon, J. W. (2011). Agendas, alternatives, and public policies (Updated 2nd ed.). Longman.

Sadowski, L. S., Kee, R. A., VanderWeele, T. J., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. JAMA, 301(17), 1771-1778. https://doi.org/10.1001/jama.2009.561