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Dialysis for Patients With End-stage Renal Disease Who Are Homeless

ARTICLE: Dialysis for Patients With End-stage Renal Disease Who Are Homeless

AUTHORS: Tessa K. Novick, Crystal A. Gadegbeku, Deidra C. Crews

JOURNAL: JAMA Intern Med. 2018 Nov 5. doi: 10.1001/jamainternmed.2018.5470. [Epub ahead of print]

End-stage renal disease (ESRD) affects more than 700 000 individuals in the United States and accounts for $33 billion in annual Medicare spending.1 Since 1973, the Medicare program has provided health coverage for most individuals with ESRD regardless of their age. About 34% of people with newly diagnosed ESRD live in areas where more than 1 in 5 households are below the federal poverty level.2 Although the prevalence of homelessness among patients with ESRD is unknown, such patients would benefit from safe and stable housing. Homelessness imposes substantial barriers to good medical care.3 We highlight the challenges faced by patients with ESRD who are homeless, recommend measures to determine the prevalence and outcomes of homelessness among Medicare beneficiaries with ESRD, and propose approaches, including a federal demonstration project, to potentially improve outcomes through supportive housing.

Providing housing to people with medically complex diseases has the potential to improve their health and decrease spending on acute care.4,5 Housing programs targeting individuals with HIV infection, mental illness, and substance use disorders have expanded throughout the United States. Examples include programs that provide housing vouchers, short-term rental assistance, transitional housing, and permanent supportive housing that combines affordable housing with medical, mental health, and social services.4,5 Scattered-site permanent supportive housing pairs single apartments in existing buildings with multidisciplinary case management. Single-site permanent supportive housing consists of entire buildings dedicated to specific groups of people and offers multidisciplinary services on-site. Analyses of permanent supportive housing programs have shown reductions in hospital admissions, increased engagement in care, improvements in overall survival, and substantial reductions in acute care spending.4,5 We are unaware, however, of any such programs in the United States for patients with ESRD. Providing supportive housing with appropriate multidisciplinary services to patients with ESRD who are homeless would be an important advance.

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Kelsey Bennett