By the time Ronald Lee was admitted to Bellevue Hospital for psychiatric care in April 2022, the Manhattan facility had become a familiar stomping ground. Lee’s mental health had gone downhill after his teenage son was killed in Far Rockaway a few years before, and he said he had several inpatient psychiatric stays at the hospital.
Before his hospitalization, Lee, 67, was shuffling between family members’ couches and a veterans shelter in Long Island City. He expected to be discharged back to the shelter, although he didn’t feel mentally ready to return.
“You can't even get a good night's sleep,” he said.
Instead, after Lee had spent less than two weeks in the hospital, Bellevue staff offered him an alternative: care at a 26-bed facility in Harlem called a medical respite. Respites are programs designed to provide a place for people to stay when they’re no longer sick enough to be hospitalized, but still need follow-up care that they can’t get in shelters or on the street.
The Harlem program is one of just a few medical respite programs in the state, providing services like wound care, physical therapy and social services, while freeing up hospital beds for other patients. Respite providers also aim to connect patients with stable, long-term housing as they leave the programs.
At the Harlem program, Lee would have his own small room and receive three meals a day, checkups, and continued help managing his medication. He could stay for up to three months while a caseworker helped him look for a more stable place to live.
“After they explained the medical respite set up to me, I figured that would be better for me than being around 400 different homeless people,” Lee said.
While medical respite care has so far been limited in New York, it’s on the verge of expanding. In January, the Biden administration gave New York permission to bill Medicaid for the service, opening up a new funding stream. There are currently two respites in Harlem that have about 100 beds between them, and at least another two upstate. The state health department is offering nonprofits $50,000 grants to open another eight.
Health officials say the goal is to improve patient outcomes while reducing overall health care costs. Federal support for medical respite past 2027 will depend on whether New York can show that’s happening.
Medical respite is part of a new slate of housing and nutrition benefits that Medicaid will cover for vulnerable New Yorkers as part of an effort to reduce overall health care spending. The federal Medicaid waiver for these services comes with $7.5 billion in funding that will help set up new regional networks of health and social services for Medicaid recipients, as well as provide aid to distressed hospitals and address other health system needs.
Nonprofits’ willingness to face this new challenge will depend on how much Medicaid pays for it, which has yet to be determined, said Bonnie Mohan, executive director of the Health and Housing Consortium, a group of social services organizations. She added that she is already concerned that the start-up grants the state is offering won’t be sufficient for some organizations.
And even now, the respite service faces some particular challenges in serving undocumented patients. People who are undocumented don’t generally qualify for subsidized housing, meaning they’re more likely than other respite patients to wind up back in shelters, instead of connecting with more permanent housing. Medicaid won’t cover their care under the new funding model, but NYC Health + Hospitals says it will continue paying for the service for those patients.
The public hospital system and some private hospitals are currently paying for respite care themselves, under the assumption that it’s cheaper than keeping people in the hospital.
“People were living in our hospitals who might have just needed once-a-day wound care,” said Marjorie Momplaisir-Ellis, a senior director at NYC Health + Hospitals’ Housing for Health program. “The ability to discharge people to medical respite allows us to take on [other] patients who actually need the care — and patients who might actually be able to pay for the care.”
Ronald Lee in the kitchen of his apartment in Jamaica, Queens. He says he is able to eat better here than he could in a shelter, now that he can cook for himself.
How medical respite is working so far
The respite model is gaining traction in other parts of the country. There are now 145 respites across the United States, more than three times as many as there were in 2012, according to the National Institute for Medical Respite Care, which is working to standardize and grow the model.
Years of research has found that homeless patients tend to use the hospital more than those who are housed. Nationally, homeless people visited the emergency department at nearly five times the rate of those who were housed between 2015 and 2018, according to the Centers for Disease Control and Prevention.
And getting people housed can help reduce hospital use and drive down health care spending overall, according to health officials. A 2018 study found that in the two years after homeless New Yorkers with mental health issues moved into supportive housing, their Medicaid costs dipped $9,526, on average.
Studies on medical respites in other states have found such programs can reduce the likelihood that homeless patients will return to the hospital shortly after being discharged, cut back on the amount of days they spend in the hospital overall, and in some cases, save money on costly hospital care.
NYC Health + Hospitals has a nearly $18 million, five-year contract with Comunilife and the Institute for Community Living, which run the two Harlem respite programs.
But so far, the city doesn’t have data on actual savings, said Stephanie Buhle, a spokesperson for NYC Health + Hospitals. She said officials hope to conduct a formal study of the program in the future.
Still, NYC Health + Hospitals officials say the service is filling an important gap in the health system, while also connecting a small portion of the 50,000 homeless patients their hospitals see annually to longer-term housing. NYC Health + Hospitals has referred more than 1,100 patients to the medical respites in Harlem since it began contracting with them in 2020. Lee is one of about 300 patients, or 27%, who was then connected to more stable housing through the program.
Housing stock in New York City is currently at an all-time low. But representatives for Comunilife and the Institute for Community Living said they have an advantage in connecting clients to housing: Because they are broader social services organizations, they also operate their own supportive housing programs.
Still, supportive housing comes with attached social services and is primarily for people with mental health issues, and not everyone who passes through respite falls into that category. Some of the patients the city is counting among the housed were reunited with family or placed in assisted living facilities instead. Others received help finding affordable or market rate units.
People were living in our hospitals who might have just needed once-a-day wound care. The ability to discharge people to medical respite allows us to take on [other] patients who actually need the care — and patients who might actually be able to pay for the care.
Medical respite is just one part of a broader array of initiatives NYC Health + Hospitals has launched in recent years to connect patients to housing under its Housing for Health umbrella. The system is also providing some patients with help navigating their housing options, and leasing out hospital property for new residential buildings. Overall, Housing for Health connected 600 people to some form of housing in its first two years, the city announced last May.
“It’s not enough to care for unhoused New Yorkers in the emergency room and then discharge them if they have no home to recover and heal in,” Mayor Eric Adams said of the Housing for Health program in 2022.
Changing patients’ health care habits
In recent years, NYC Health + Hospitals has pushed patients to use more primary care and outpatient services, rather than rely on the emergency room. Some medical respite patients say they are changing their approach to their health after going through the program.
Lee said it’s been easier to focus on improving his health since he was placed in a supportive housing apartment in Jamaica, Queens. He’s gotten a hip replacement and dental work since going through the respite program, and had a lipoma removed from his neck — a lump that can, in rare instances, be cancerous.
“This last year I've gotten three different physical things done,” Lee said. “It’s like a remix of my whole entire body.”
Lee has also stopped going to Bellevue for all his mental and physical health needs, and instead works with local clinicians near his apartment. He can also call his therapist or his caseworker at the respite he visited, known as the Institute for Community Living.
Respite can also help sort out health care issues for undocumented patients who can't get connected to permanent housing right away.
About half the clients at the Institute
Nearly half of the clients at the Institute for Community Living are undocumented, according to Program Director Ingra Dabreo. Still, she said, the respite can at least request a “reasonable accommodation” from the city’s Department of Homeless Services based on a patient’s medical needs, so that the patient might get admitted to a safe haven or low-density shelter, rather than a large congregate space.
Reynaldo Medina, a 72-year-old undocumented client at the center, spoke through tears about how grateful he was for the program earlier this month, even though he knew he would likely be discharged to a shelter. Medina has been homeless for decades and ended up staying at Elmhurst Hospital in Queens for three months after a fall in late August. He said he had previously avoided doctors because of the potential cost.
While at Elmhurst, Medina found out that he had undiagnosed diabetes, which he said he is now getting under control.
Medina has been at the respite since November and said he has received wound care for a bed sore he developed in the hospital, as well as physical therapy and transportation to his medical appointments. He also said his caseworker is also helping to connect him to legal assistance to sort out his immigration paperwork.
Lee is also more optimistic about his own future now.
“I'm going to be around for a while,” Lee said. “I told my kids I'm gonna see if I can give them another 40 years.”
