Discharge Planning Advisor

Homeless pose unique discharge challenge

Hospitals often face 'lose-lose situation'

In the wake of a first-of-its-kind settlement regarding the discharge of a homeless woman by a Kaiser Permanente hospital in Southern California, indications are that the disturbing issues it aims to address are far from unique.

Under the settlement agreement, the HMO is required to establish new discharge rules, provide more training for employees, and allow a former U.S. attorney to monitor its progress. Kaiser also will contribute $500,000 to a charitable foundation that supports the expansion of recuperative beds in Los Angeles County and a project to develop an electronic database linking county shelters and hospitals.

The case involved a 63-year-old patient who was discharged from Kaiser's Bellflower Medical Center in March 2006. A video at a downtown mission shows the woman apparently being dropped off by a taxi and then wandering aimlessly, clothed in only a hospital gown and slippers. After several minutes, officials from the Union Rescue Mission escorted her into a nearby building.

As horrifying as it is to view that incident — and similar ones recorded since the action against Kaiser was filed in late 2006 — the "dumping" of homeless patients often is the ultimate result of a "lose-lose situation" for hospitals that have exhausted their options, suggests Kate Tenney, RN, manager of case management at Sutter General Hospital in Sacramento, CA.

"That could easily have been us," adds Tenney. She says Sutter Health started its interim care program, aimed at meeting the challenges presented by the homeless population, after community service organizations expressed concern that homeless patients were being discharged back to the streets before it was medically appropriate.

What frequently happens in such cases, Tenney explains, is that discharge plans collide with patient choice. Referring to a similar case — which also drew media attention — in which a man with a colostomy, wearing a soiled hospital gown, was dropped off at a city park, she says, "I bet the discharge planners tried to get him to go to a skilled nursing facility, and he probably refused because he didn't want to spend his general assistance money."

Her experience, she adds, is that homeless individuals often balk at signing over the funds they receive from the state so they can gain admission to a skilled nursing facility or other post-acute care.

Giving up that money "eliminates the ability to go out and buy a fifth of whiskey every other day," Tenney notes. "So then you have the patient saying, 'I don't want to do anything you're suggesting and I want to stay here.' That's why hospitals get in this situation."

It's also likely, she says, that the homeless person in such a case would tell shelter officials that he was "thrown out" by the hospital.

After meeting with advocacy groups, case managers from Sutter Health and two other major hospital systems created the interim care program, which resulted in the establishment of a homeless shelter specifically designed for people who need care after discharge.

The latest phase of the Sutter program is called the "T3 Continuum Project," which focuses on designing ongoing primary care and housing solutions.

Is it the government's responsibility?

Dealing with the problems associated with the homeless is actually the government's responsibility, says Tenney. That view is shared by several leading advocates for the homeless, who cautioned that the Kaiser decision is not a panacea for deeper structural issues of how local, state, and federal governments deal with Los Angeles' large homeless population, according to an article in the Los Angeles Times.

In addition to the provisions already mentioned, Kaiser agreed, in its settlement, to pay $5,000 in civil penalties and $50,000 in investigative costs to the city attorney's office. The foundation to which it made the $500,000 contribution also will fund a free legal clinic in Skid Row to assist eligible homeless people in getting health benefits.

Under the terms of the protocol, Kaiser must do the following:

  • Take precautions with homeless patients, logging them into a special record and documenting all of their belongings, which must be returned to them on discharge.
  • Require physicians, nurses, and social workers to assess and document homeless patients' mental status and refer them for cognitive and neurological exams when needed. If a member of the medical staff questions the person's ability to understand a discharge, the discharge will be delayed.

If the hospital fails to comply with the agreement, the court can levy fines or jail time. The injunctive provisions of the agreement will last three years, but Kaiser will be allowed after a year to request that they be dropped if it can show compliance with the conditions and protocol of the order.

Sutter General has had numerous patients show up at its emergency department (ED) who "come to find out were in somebody else's hospital two days ago," Tenney says. "Two were from the state of Washington. They arrived at the bus station and were so debilitated that the people there brought them to our ED. The hospital in Washington had bought them a one-way ticket to Sacramento."

Staff at the original facility "probably said, 'They have lots of homeless places down there,'" she adds.

In both cases, Sutter took action through the Washington State Ombudsman Program, "which was very helpful in getting the two patients back to facilities in that state," Tenney says. "It turned out there were skilled nursing facilities that were sending patients down here."

Facilities get a reputation as places where the homeless may be sent, she notes, suggesting that the Kaiser hospital may have "believed that sending them to Skid Row was a good solution." That won't change, Tenney adds, if the receiving facility doesn't do anything about it.

"Having every small community in the nation have shelter beds is expensive," she notes, "so suddenly you have a homeless person show up in the hospital" and the question of what to do with him or her. That's especially true, Tenney says, "if they need ongoing care — and they always need ongoing care."

(Editor's note: Kate Tenney can be reached at TenneyK@sutterhealth.org.)