Discharge planning and the dilemma of dealing with homeless patients

What do you do when they want to live on the street?

The camera got it all on tape: A taxi disappearing from view and then 63-year-old Carol Ann Reyes, clad in a hospital gown and slippers, wandering San Pedro Street in the Skid Row area of Los Angeles until someone escorted her into the nearby Union Rescue Mission building.

Reyes, who had been hospitalized for three days at Kaiser Permanente's Bellflower facility, later told reporters she could not remember what happened when she left the hospital or how she got to the place where she was found.

According to the Associated Press, several hospitals have acknowledged that they send patients who have nowhere else to go to that area because the services and shelters are there.

Jim Lott, executive vice president of the Hospital Association of Southern California, says the problem has been blown out of proportion.

"More homeless people are dropped off in downtown LA by law enforcement officers than by hospitals. Homeless patients need a lot of outpatient care, but not that many are hospitalized," he says.

There are about 80,000 homeless people in 88 different cities in Los Angeles County, but the vast majority of the services available for the homeless are in the city, Lott says. "When the homeless are discharged from the hospital or let out of jail, they are brought into the city because that's where they can get help," he says.

The Reyes incident made national news, but left unexplored in most press accounts was the larger issue of how hospitals are supposed to deal with patients who have no fixed address, no income, and no family or social support.

"The number of homeless is increasing in many communities, and it's not being dealt with effectively. People with mental illness, alcohol, and drug problems have long been among the homeless, but in recent years, more families are hitting the street as a result of job loss," says Kathy Hearne, MSSW, coordinator of respite care providers for the National Healthcare for the Homeless Council, with headquarters in Nashville, TN.

And no matter how hard case managers and social workers try, there are some homeless people who simply don't want to go to a shelter.

"Some individuals who are homeless choose to be homeless, and they remain homeless when they leave here, no matter what we do," says Greg Jensen, ACSW, LISW, director of social services for the University of Iowa Hospitals and Clinics in Iowa City, IA.

"The homeless come to the hospital only as a last resort. They don't come looking for anything more than having their immediate needs taken care of," says Winnie Coburn, RN, CPHQ, director of care management for Carondelet Health Network in Tucson, AZ.

Sometimes, their friends or colleagues on the street bring homeless patients to the hospital, or they pass out and an ambulance is called, Coburn adds.

"We clean them up, get them fed and bathed and give them the medication they need and they're ready to go back on the street," she says.

When a patient is identified as being homeless at the point of admission, that should trigger a set of responses, Lott says.

"At a minimum, the staff should obtain clothing and consider giving the patient a cash allowance to get to a low-cost hotel. We do that much for prisoners. Discharging them in hospital gowns is not a good visual, nor is it humane," he says.

Informed consent

Hospitals can run into trouble if they transfer homeless patients to places they don't want to go, Lott points out. "The Los Angeles City Attorney has told us that we have vulnerability if we send patients someplace against their will," he says.

The hospital association has advised hospitals to get an informed consent from patients indicating that they agree to their discharge destination, including that they want to go back on the street.

"We do recommend that hospitals try to connect homeless patients with social services agencies before they send them anywhere. And for their protection, they need expressed written consent that that patient wants to go where the hospital is sending him," Lott says.

Hospitals are in a Catch-22 situation when patients are medically stable enough to be transferred to a lower level of care, he points out.

"Hospitals cannot discharge a patient to another medical facility unless that facility agrees to take them. It puts the hospitals in a tough bind because they shouldn't discharge patients who require follow-up care unless they know it's available," Lott says.

"We struggle like everyone else struggles to find a discharge destination for patients who are homeless. We work with their friends, with local churches, and community agencies to find a safe discharge destination," Jensen says.

At the University of Iowa Hospitals and Clinics, staff can tap into the hospital's expedited discharge funds to pay the daily rate to a shelter to house homeless patients while they recover from an illness or injury.

"So we don't burden the local resources, we can pay for two to three weeks in a shelter while the patient receives IV antibiotics or recovers more fully," Jensen says.

"Each case is unique. Minimally, we work with a homeless shelter and see if we can reimburse them for some of their services. If a patient needs IV antibiotics, we provide them," he adds.

Physicians make the determination of whether a patient can be safely discharged.

"Some do stay here because they literally have no place to go. They may stay two to three weeks more than is medically necessary while they are convalescing. You just can't take someone who can't get out of bed and put them on the street," Jensen says.

Seton Healthcare System sometimes pays for homeless patients to go to an assisted living center, or a group home if they aren't ambulatory or otherwise need to recover. On rare occasions, the health care system has paid for a hotel room for patients who had a short recovery period.

"It makes good financial sense. It gets patients to the proper level of care, the nurses no longer have to care for patients who don't need to be here, and it opens up the bed for patients who have funding," says Pat Beal, LCSW, outpatient case management supervisor and Northwest Operations Manager for the Austin, TX, health care network.

A solution in some communities has been to establish a respite shelter where patients can receive around-the-clock care supervised by doctors and nurses, Hearne says.

Most shelters don't stay open during the day. People have to leave the shelter in the morning and come back at night. Respite shelters are a combination of a shelter and a health care clinic, Hearne says. Many have grown out of health care for the homeless programs in the community.

Eligible patients may include someone who has a staph infection and needs IV antibiotics or someone who is terminally ill, she says.

"You can't keep someone in the hospital when they have just a few months to live, and you can't put them out on the street. Respite programs offer an option," Hearne says.

One of the goals of the National Healthcare for the Homeless Council's annual meeting in Portland, OR, June 7-10 is to forge more relationships between hospitals and community agencies working with the homeless, she reports.

"There are no easy answers for any of this. The bottom line is that case managers have to be very creative and to engage every community resource that is available. Ask everybody for help and keep asking. All they can do is say no," Coburn says.