Creativity is the key in discharge planning for undocumented immigrants
Creativity is the key in discharge planning for undocumented immigrants
Tap into as many community resources as possible
Hospital discharge planners must use their ingenuity to find a discharge destination for undocumented workers who need post-acute care.
"Finding post-acute care for documented workers means starting from scratch every single time and tapping into whatever community resources are available, says Caroline Keane, RN, MSN, ANP, CCM, director of case management and social work for New York Hospital-Queens, a private, nonprofit hospital in downtown Flushing.
Hospitals are compelled morally and by law to treat anyone who comes in with an emergency condition under the Emergency Medical Treatment and Active Labor Act (EMTALA), points out Carla Luggiero of the American Hospital Association.
"Over the last 10 years, our hospitals have noticed an increase on what we suspect are undocumented immigrants coming into the emergency room," she reports.
In 2000, hospitals in just 24 counties along the Mexican border spent more than $200 million on emergency health care and transportation for undocumented immigrants, according to a study by the Border Counties Coalition.
The undocumented are a subset of the uninsured whose care often strains a hospital's budget, Luggiero notes.
"It gets to be a matter of allocating funds. If a hospital has a large number of uninsured patients coming to their emergency department, they have to allocate funds to that at the expense of other programs," she says.
In 2004, the Centers for Medicare & Medicaid Services (CMS) announced a program to provide $1 billion over a four-year period (2005-2008) "to help hospitals and other providers recoup the costs of providing needed medical care to uninsured patients who cannot pay their hospital bills regardless of their citizenship status," according to a CMS statement. Part of the Medicare Modernization Act, the program, "proposes to allocate payments based on the costs incurred for the initial emergency services and associated services, including physicians and ambulance services."
But hospitals are likely to get only a few cents on the dollar when they apply for the funds, Luggiero points out.
"This program does not fully cover the cost of providing emergency department care. It's pennies on the dollars," she says.
Funding is allocated to states based on the proportion of illegal immigrants in their state compared to the national proportion, with extra payments going to states with the highest rate of apprehending illegal immigrants, Luggiero says.
"An illegal immigrant who's been in an accident and has head trauma, internal bleeding, and multiple injuries could deplete the entire amount allocated to the state," she says.
It's hard to know exactly how many undocumented immigrants are being treated in U.S. hospitals because citizenship isn't something that usually is included on admissions forms, Luggiero says.
Some illegal aliens tell hospital staff up front that they don't have papers, she says. Among those who don't say if they don't have an address in the United States or a Social Security number, it's a good guess that the person is undocumented, Luggiero adds.
Hospitals are limited by HIPAA regulations when it comes to finding out information about patients from community organizations or government agencies, Keane points out.
Some patients come in confused and may have a green card but are unable to tell the hospital. This means that it is difficult for the hospital able to apply for Medicaid on behalf of the patient.
"At one time, we could call the Social Security Administration to find out if a patient had a social security card. It's not as easy as it used to be. We just have to do the best we can," she says.
Beginning July 1, states must verify that a person applying for Medicaid is a U.S. citizen, a naturalized citizen, or has been living in this country legally for five years, Luggiero says. People who apply for Medicare must have a Social Security number.
When the patient is undocumented and needs post-discharge services, the problem becomes more challenging for discharge planners. Since post-acute facilities are not compelled to take unfunded patients and illegal immigrants can't qualify for Medicaid or other publicly funded assistance programs, they often end up staying in the hospital for long periods of time.
"The first thing we have to do is treat the patients who present at the emergency room. Then we worry about insurance and what will happen later. We do our best to find family members or someone else who can take care of them after discharge," says Winnie Coburn, RN, CPHQ, director of care management for Carondelet Health Network in Tucson, AZ.
Hospitals are required to provide a safe discharge to all patients, unless they sign out against medical advice or just walk out of the hospital, Coburn points out.
Post-discharge services
Undocumented workers tend to fall into two groups — those with supportive families and those who have no relatives and few friends in this country, Keane says.
Patients who have been in the United States a long time and have ties in the community often have friends or family members willing to take over the care.
For instance, New York Hospital-Queens recently treated a hemiplegic patient who had a family in the city who was willing to take care of him after discharge. The case managers were able to reach out for charity care from local home care agencies and to get medication from a program for the indigent. They got a wheelchair and other equipment through a durable medical equipment company's charity program.
"We see how many hours of home health they need and see if we can work it out with nursing services. It's the easiest to find when the family is still involved," she says.
Migrant workers are the hardest to place if they need post-discharge services, Keane says. These workers typically come to the United States alone and send money back to their family in their native country.
"Home care is a big deal for us. We look at individual cases and try to find a discharge destination if we think somebody is going to need services after discharge. We can't discharge them if they aren't going to be safe," she says.
The living situation of undocumented workers often makes it difficult to provide a hospital bed, a walker, a wheelchair, or other equipment they may need after discharge, Keane adds.
"They may be living in an apartment with a lot of other people. Even if we provide them a hospital bed or other equipment, there may be too many people living in a small space to accommodate it, even if it's just on a temporary basis," she says.
If the patient needs help with toileting or other activities of daily living, they don't always have someone who can help.
Some undocumented migrant workers have created their own version of an extended family with friends and roommates who can provide care, Keane says.
For instance, she's been able to find friends who can come in the morning and the evening to take care of the patient while he or she recovers.
"If you're not looking for care to last indefinitely, sometimes it can work. You just have to try to tap into every resource you can and keep looking until you find a solution," Keane says.
Sending patients back to their native country is another solution. New York Hospital-Queens has paid to transport disabled patients back to their homeland if they can find family members who want to take care of them.
In one case, a bilingual nurse explained the care needs to the family, and the hospital paid for the airfare for a family member to come to New York and travel back with the patient.
"The family really did want him/her back home. You can never assume anything. We've had patients who have been in this country illegally for 10 years but when they are sick, their wife or their child may want them back," Keane says.
Keane was able to send one patient from China back to his family with the help of a local church. The patient wasn't able to fly alone so the church helped find someone who was going to travel to China and who agreed to accompany the patient.
"Rather than arranging a medical airlift, with the help of the church, we were able to find someone to accompany him," she says.
The hospital introduced the church member to the patient and paid for his airfare.
On the other hand, sometimes, it doesn't help to find family members. The case manager tracked down an adult son of one injured patient who was an undocumented immigrant, but the son said he had seen his father twice in his life.
"There was no connection there. He wasn't willing to have his father come and live with him and his family," she says.
The social workers at Carondelet Health Network in Tucson work with the Mexican Consulate, which sometimes can help the hospital locate family members who are willing to care for the patients at home.
"We try to find family or friends in the United States and work with the consulate on family connections in Mexico. We try to transition them to another level of care, but if they continue to need care and there is no discharge opportunity, it is our obligation to complete the care," she says.
On occasion, the hospital has been able to transfer the patients to a hospital in Mexico where they can get care closer to their families.
Recognizing that some Mexican hospitals may not be as well equipped as their counterparts in the United States, some hospitals in Tucson have been helping a hospital just over the Mexican border obtain improved equipment so patients can be safely transferred and receive the care they need, Coburn says.
Case managers and social workers often tap into community resources to find a safe discharge destination for undocumented workers, Keane says.
"Some facilities are very generous, and if they have an empty bed, they will take an unfunded patient," she says.
Some facilities in New York have a program geared toward the Asian population, and if they have an extra bed, they'll take an undocumented Asian patient who needs post-acute care.
If the patients are homeless as well as undocumented, the hospital immediately contacts the city's shelter system to see if the patient meets its criteria.
The case managers work with assisted living facilities and adult care homes for placement when patients don't fit into a skilled nursing bed but need post-acute care.
"It's cheaper than keeping them in an acute care hospital when they don't have acute care needs," she says.
Hospital discharge planners must use their ingenuity to find a discharge destination for undocumented workers who need post-acute care.Subscribe Now for Access
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