Henry C. Fader
Carolyn N. Phillips
Hospitals need effective policies for discharging homeless patients, who, without such policies, would likely soon return to the ED only to be readmitted as inpatients.
At a Glance
- Homeless patients who lack access to the health resources they need to maintain their health on their own pose a challenge for hospitals: Premature discharge of such patients can result in their being readmitted to the hospital in a short time, leading to higher costs for the hospital.
- Hospitals can address this problem by developing clear, effective homeless discharge policies and by developing ongoing relationships with appropriate medical respite care providers.
- A hospital also can benefit from spearheading an initiative to develop a medical respite program, enlisting the assistance of other community stakeholders.
The global economic downturn has many social workers and clinicians alarmed by growing the number of homeless individuals going to the nation's hospitals for health care. An influx of newly homeless, adding to large numbers of chronically homeless, is forcing healthcare organizations to take steps to ensure that they have legally compliant discharge planning protocols and procedures in place to avoid frequent readmissions or charges of "patient dumping."
Two forces are increasing the numbers of homeless patients who are receiving care at U.S. hospitals: Economic hardships are driving patients to homelessness, increasing the likelihood that they will require charity care, and adverse living conditions faced by already homeless patients who have chronic or acute illnesses are exacerbating these illnesses.
Many of these homeless individuals and families are routinely exposed to the elements, communicable diseases, violence, malnutrition, and drug and alcohol abuse. Their illnesses often are concurrent with psychological and substance abuse, making them more difficult to treat in an acute care setting. They also typically enter the hospital through the emergency department (ED), and if they cannot be transferred properly, they must be kept in the ED or admitted for treatment of their acute illnesses as inpatients.
Hospital staffs have names for such patients: All too often, the patients are referred to as "revolving-door" or "frequent-flyer" patients because-lacking health insurance and sufficient resources to care for themselves or their families-they tend to be readmitted repeatedly for the same conditions. They also are sometimes called "bed blockers," which expresses the frustration many caregivers feel in dealing with these patients' increasingly extended inpatient stays and the feeling that all of their efforts to deliver effective care are futile.
The use of such terms, while they may be seen as pejorative, reflects an unfortunate reality in the nation's hospitals, today. That is, many caregivers perceive that indigent homeless patients are using valuable assets and consuming the most expensive level of care to no good purpose. The problem is that often, after these patients have been diagnosed and stabilized in the ED, they are deemed not to require inpatient treatment and could be discharged, yet they remain in the acute care bed because they have no place to go to receive follow-up care after discharge. Even if discharged, they often return to the hospital in a short time because they lack access to follow-up care. Such results point not only to the problem of the lack of adequate care for these patients, but also to higher costs for hospitals that have not found a way to cost-effectively address these patients' needs.
Solutions to these problems can take many forms, but two warrant special consideration by hospital finance leaders: developing well-thought-out and anticipated discharge policies to cover patients who lack stable settings, and developing a communitywide respite or recuperation program. Proper discharge planning and using medical respite care can significantly reduce the incidence of readmissions of homeless and other vulnerable patients. In view of the significant financial benefits in reduced costs that can be gained from achieving such results, hospital finance leaders should give due consideration to both of these solutions.
Hospital finance leaders should ensure that their organizations have clearly defined and consistently implemented policies in place regarding discharge planning for homeless patients.These policies should be developed with a clear understanding of various laws and regulations that have a bearing on a hospital's approach to discharging homeless patients. (See Legal Statutes and Regulations Applicable to Homeless Discharges)
The hospital's homeless patient discharge planning policies should, first and foremost, state that the hospital will use all best efforts not to discharge a homeless person-in particular, any individual with a history of mental illness who is not managing his or her disease without social supports-back to the streets or to a homeless shelter. Discharge to a shelter should be part of a plan only as a last resort. Hospital management should provide employees with incentives to engage homeless patients in dignified discussions, rather than just documenting "refusals" with a check mark on a list of required questions.
As an example, healthcare organizations can reward discharge planners and social workers who work with these difficult patients by recognizing them for their contribution to the entire treatment team in the effort to avoid costly readmissions. Such workers also can be given incentives for participating in team care meetings and helping to identify issues that could lead to a readmission and prevent them from occurring. Discharge workers also can receive greater and more supportive supervision through questioning aimed at determining the extent of their efforts to obtain information to make the discharge process more successful.
For example, a worker who routinely completes discharge records with statements such as "The patient refused to provide information" could be asked how much time he or she actually spent speaking with the patient, and what attempts he or she routinely makes to reengage a patient who initially refuses to provide information.
Workers should receive guidance to express empathy and use open-ended questions with homeless patients when they are attempting to determine how receptive the patients are to sharing information:
- How did you become homeless?
- Were you in the military? Can you tell me about that?
- Are you concerned for your safety when you are on the street?
The organization's discharge planning process also should ensure that staff and physicians know how to identify a frequent user immediately upon arrival at the hospital (even if social work staff has gone home for the day). Staff should be instructed to critique reasons for the arrival holistically, in the context of the patient's history and homeless circumstances, rather just focus on a narrow reason for the visit (such as a wound). Such critiques should also consider the last admission or ED visit, whatever the reason.
The discharge planning process should seek to identify the factors that are leading to hospital re-entry. If a wound is the cause of the readmission, for example, but the patient also has a history of mental illness, then the wound might have been due to the patient's going off the medications prescribed for the mental diagnosis. In such an instance, the mental illness should be considered a major factor contributing to the rehospitalization. Given the inherent difficulties involved with a transfer to a psychiatric or substance abuse treatment facility, the hospital's homeless patient discharge planning process should include a well-thought-out policy for such transfers, including established relationships with appropriate facilities. Such policies should include reassessment of the patient after admission and periodically thereafter, including a reassessment prior to discharge. If the discharge planner determines that the patient cannot successfully follow the discharge plan ( e.g., keep outpatient appointments, take medications, and find transportation), the patient will inevitably be readmitted.
The key question to be asked is whether the previous discharge plan for the patient worked to keep the patient out of the hospital. If not, the discharge planners should modify the plan and make sure the patient can understand it.
Hospitals should also avoid the practice of expediting the discharge of homeless patients immediately upon meeting the stability requirement under the Emergency Medical Treatment and Active Labor Act (EMTALA)-a practice that can lead to premature discharge. If staff members conclude that the patient is stable but that his or her stability is tenuous and likely to deteriorate materially upon discharge according to the usual discharge plan, then the discharge plan should be changed, and available respite or recuperative care options should be considered.
In short, any discharge plan that could foreseeably result in a readmission should be reviewed and changed. Establishing as policy a thorough review process avoids the egregious mistake of allowing a discharge plan to be issued that is factually impossible to implement, such as "OK to discharge home" written in a homeless patient's chart-which would be an obvious red flag for knowledgeable risk managers, as well.
Respite or Recuperative Care
In addition to implementing effective homeless discharge planning, hospital leaders also should anticipate the increased entry of homeless frequent users by engaging in relationships with providers of respite care and other outpatient healthcare and case management providers, or by developing the means to deliver such care. Hospitals should have memorandums of understanding with these providers, defining the relationship and processes that will be followed to ensure that the patients will receive needed care after discharges.
To this end, finance executives should gain an understanding of postdischarge care initiatives that have been shown to alleviate some of the costs of care attributable to revolving door and frequent-flyer patients. A single hospital or health system can develop such an initiative on its own, but such an approach requires caution to avoid attracting a disproportionate share of the community's homeless population to the organization.
Most successful projects have been developed on a communitywide or regional basis. A 2006 study evaluating respite care projects in Chicago found that patients discharged to medical respite care had significantly fewer inpatient days and ED visits than did patients discharged back to the street (Buchanan, D., Doblin, B., Sai, T., and Garcia, P., "The Effects of Respite Care for Homeless Patients: A Cohort Study," American Journal of Public Health, July 2006).
According to the National Health Care for the Homeless Council, homeless patients have been shown to have 50 percent fewer hospital readmissions within 90 days of discharge if they receive respite care ("Medical Respite Care: Reducing Costs and Improving Care," Policy Brief, April 2011).
In particular, the survey reports that cost per day for medical respite or recuperative care in the areas included in the survey is less than 10 percent, on average, of the cost of a daily acute care hospital bed in the same areas. Following are some examples of average daily hospital inpatient costs, based on Kaiser Family Foundation data, compared with daily costs for medical respite care, respectively, for some of the states included in the survey:a
- San Francisco: $2,279 versus $180
- Fort Lauderdale, Fla.: $1,722 versus $125
- Chicago: $1,856 versus $90
- Houston: $1,859 versus $125
- Richmond, Va.: $1,698 versus $68
Types of respite care. Respite care can be defined as short-term residential care that provides post-discharge care to patients who require such care in a safe environment. Funding, governance, operations, and licensing (if any) vary depending on the community. Some models employ a case management system, in which the care is provided where the patient receives housing assistance. Other models are facility-based in unused wings of nursing homes or hospitals or in transitional housing. Respite programs allow patients access during their stay to medications, supplies, equipment, labs, physicians, and nursing care. Length of stay can vary depending upon the needs of the patients. It can be as long as 100 days.
Funding can be on a per diem or episodic basis, or via annual contributions to operating costs with bed reservations. Hospitals are a primary source of funding for medical respite programs. Hospitals that wish to sponsor such a program should consider partnering with low-income and transitional public housing developers because such developers offer the advantage of being familiar with federal housing grants and homelessness prevention funding.
Development of a medical respite program. For hospitals, developing a medical respite program in the community is similar to participating in other communitywide projects. The simple goal is to create an environment where each homeless patient is treated with respect and receives the outpatient care he or she needs, while reducing the hospital's financial burden of holding the patient in an acute care bed.
First, the hospital should perform a preliminary needs assessment and determine the extent of the homeless discharge impact across the community, not only on the hospital. The hospital should then approach various community stakeholders-other hospitals, homeless shelters, charitable organizations, and government and public health officials-to solicit their participation in the project. Together, the hospital and its partners should analyze the scope of the community's homeless discharge needs, discuss funding mechanisms for capital and operating costs, and develop the model and program design.
Once these key decisions have been made, they should implement and market the program. Of course, as with all programs that attempt to change the way care is delivered, data collection and evaluation are critical elements in determining the program's effectiveness in meeting the respite project's goals and objectives. They should track the program's successes in lowering readmission rates on an ongoing basis as those numbers start to decline.
Case Examples of Communitywide Effort
In recent years, two programs have demonstrated how proper discharge and follow-up care can reduce readmission of the homeless and frequent users of acute care services.
Camden Coalition of Healthcare Providers. Under the leadership of Jeffrey Brenner, MD, founder and executive director, and funded by the health systems located in the New Jersey community, this program uses technology to track homeless and low-income patients who go to any of the area's hospital EDs. The patients are assigned to the program and the organization's team of clinical street workers. Using a care management program, this team focuses on stabilizing the homeless patient's social environment and health condition and finding appropriate housing for the patient. The goal is to prevent ED visits. The results have been a 40 percent reduction in ED visits for the target patients and a 56 percent reduction in these patients' overall hospital charges, some of which are reimbursed, with the remainder representing write-offs.
Alameda County Medical Center. In California, responding to legal and payment incentives to improve population health among frequent users and contain costs, Alameda County Medical Center and the independent Alameda Health Care Services Agency have developed discharge policies and procedures for homeless and mentally ill patients and have aligned planning goals for the desired long-term health outcomes for the patients.b Alameda County directs discharge-planning efforts toward coordinating housing and support, community-based primary care, and case management. Alex Briscoe, deputy director of the Alameda Health Care Services Agency, has called upon providers to identify the seven top chronic diseases of their frequent-user population, access social and environmental triggers that drive unfavorable outcomes, and eliminate those triggers.c Alameda has formed strategic relationships and created projects and alliances to become a leader in achieving success in managing the illnesses of the homeless and mentally ill outside of the hospital.
In the End, It's About Mission
Homeless patient discharge planning in hospitals involves the merging of legal compliance with sound risk management and financial planning to lower costs and improve outcomes. This effort will require technological innovations, data collection, and tracking of results. Hospitals that improve their own protocols and procedures, tackle tough issues that drive unfavorable health outcomes in the focus population, and enlist the support of community resources in creating outpatient "homes" for the homeless will not only contain costs, but also better accomplish their core mission of delivering the highest quality of care to their communities.
Henry C. Fader, JD, is a corporate and healthcare partner, Pepper Hamilton LLP, Philadelphia (firstname.lastname@example.org).
Carolyn N. Phillips, JD, DCA, is a deputy city attorney, Los Angeles City Attorney's Office, Los Angeles.
a. Although the locations are identified here by major cities, the survey report indicates that these figures reflect amounts at the state level.
b. An example of these incentives is California's new Section 1115 Medicaid waiver, which creates the Delivery System Reform Incentive Program, a federal pay-for-performance initiative for public hospitals that improve quality and outcomes in frequent-user populations and contain costs.
c. These top chronic diseases are often cited as being drug and alcohol abuse, depression and mental illness, hypertension, chronic bronchitis, HIV/AIDS, asthma, and arthritis, but other common chronic diseases include gastrointestinal disorders, neurological disorders, chronic obstructive pulmonary disease, and peripheral vascular disease.
A Growing Challenge
The federal government, in conjunction with state and local governments and not-for-profit organizations that deal with the homeless, compiles statistics on their growing numbers. These statistics underscore the point that many healthcare organizations-whether urban academic medical centers, suburban community hospitals, or rural hospitals-are touched daily by the issue of how to properly discharge homeless patients who have been admitted to their care.
The U.S. Department of Housing and Urban Development (HUD) reports that in the 12-month period of Oct. 1, 2008, through Sept. 30, 2009, nearly 1.56 million people used an emergency shelter or were provided transitional housing assistance in the United States (The 2009 Annual Homelessness Assessment Report to Congress, June 2010). According to HUD's annual one-night count of the homeless in the United States in January 2009, about 643,000 persons were occupying shelter beds or were unsheltered on the streets of our cities, suburbs, and rural municipalities. Of that number, only 63 percent were actually in a shelter or housing, with the balance finding places to stay that were unsafe, unsanitary, and without adequate support (such as lacking food and water) in cars, abandoned buildings, and highway underpasses not meant for human habitation.
Particularly troubling among HUD's statistics on the U.S. homeless population is that roughly 10 percent are military veterans. Family homelessness rose from 131,000 in 2007-the prior time when families were counted-to 170,000 in 2010.
The Los Angeles Experience
Nowhere in America is homelessness more pronounced than in Los Angeles, where more than 240,000 men, women, and children experience homelessness each year. Downtown, a 50-block area known as Skid Row was used for decades to "contain" the homeless. Over time, almost all of the region's emergency shelters became concentrated in the one neighborhood in Los Angeles in which their occupants were tolerated.
Because the shelters were there, Skid Row became a magnet for hospitals discharging homeless patients. Patients were seen clutching written orders stating "discharge to home." The high number of hospital drop-offs created a burden on homeless shelters, paramedics, and police, as well as a "revolving-door" from hospitals, streets, jails, and courts and back to the hospital again.
The Los Angeles city attorney has obtained final stipulated judgments and injunctions against several hospitals for dumping patients in Skid Row, and forced mandatory training and education requirements.
The most significant civil cases involved the College Hospitals in Costa Mesa and Cerritos. The case was prompted by College Hospital Costa Mesa's handling of the discharge of a psychiatric patient. At the time of discharge, the patient could not return to his usual placement, and his family had not been notified of the pending discharge. The hospital dropped the patient off at a homeless shelter, which was unable to care for him. The next day, the patient was picked up by a van sent by the hospital and then dropped off in front of another shelter a few miles away. The patient wandered away from the shelter and eventually made his way to a downtown clinic, with the result that his family was finally contacted and he was released to a psychiatric board-and-care facility. A judgment for $1.6 million was entered in 2009 in favor of the City of Los Angeles. (See DiMassa, C.M., and Winton, R., "College Hospital to Pay $1.6 Million in Homeless Dumping Settlement," Los Angeles Times, April 9, 2009).
An important result of the College Hospital case was the hospital's release of a document outlining best practices in homeless discharge planning. The document, College Hospital's Best Practice on Psychiatric Homeless Patient Discharge Planning, is publicly available at the website of the Los Angeles City Attorney's Office.
More About the Camden Coalition of Healthcare Providers
To learn more about this organization and how it came about, read "The Hot Spotters" by Atul Gawande, published in the Jan. 24, 2011, issue of The New Yorker.
Publication Date: Thursday, March 01, 2012