By Melinda Young
A California law that mandates discharge planning measures for homeless patients could be replicated in other states as homeless populations create major healthcare issues.
• Hospitals had to scramble to meet the mandate’s specific rules, but have adjusted to procedural changes and more documentation.
• Case managers can leverage technology to save staff time on fulfilling some of the requirements.
• Hospitals are required to ask about infectious disease and to provide vaccinations, as needed.
Hospitalizations among homeless people are on the rise, driven largely by mental illness and substance use issues.1
Homeless patients can fall through the cracks as they often do not carry healthcare coverage. Also, these populations can cost hospitals millions each year in unreimbursed care.
California recently enacted a law that addresses this issue by requiring hospitals to follow a prescribed plan for identifying and safely discharging homeless patients. SB 1152 outlines specific discharge planning measures for homeless patients in acute care hospitals. (Text of the bill is available at: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1152.)
As one report notes, “Helping people plan a successful transition from institutions like hospitals and jails is critical to preventing and ending homelessness.” (View the report at: https://www.hivlawandpolicy.org/resources/no-safe-place-criminalization-homelessness-us-cities-national-law-center-homelessness.)
“The first blush of the bill’s requirements was on Jan. 1, 2019. The next blush of requirements was approximately six months later,” says Todd McClure Cook, MBA, MSW, EdD, vice president of integrated care management at Sharp HealthCare in San Diego.
Health systems quickly adjusted to the requirements. “At first, it was a mad scramble,” Cook says.
One requirement is for hospitals to offer homeless patients food and clothing that is appropriate for the climate, he says.
“They must ask about infectious disease and provide appropriate vaccinations,” Cook says. “You have to provide the individual with a list of available resources, including different shelter possibilities in the area. We were required to provide full prescriptions for the individuals.” Before the law was passed, hospitals had to provide homeless patients with a minimal amount of medication to carry them over until they could visit a federally qualified health center, Cook explains.
The law also requires the health system to transport homeless patients up to 30 miles or 30 minutes.
“There were a lot of gray areas surrounding all of this, which gives organizations like mine — and we consider ourselves to be well ahead of the curve — a great challenge,” Cook says.
One of the bill’s more challenging requirements involves on-demand, real-time reporting of a hospital’s compliance with the regulation. Case managers perform most of the work required by the bill.
“It involves two critical areas in the hospital: the inpatient side of the hospital, when someone is admitted, and the outpatient side, which includes all of those patients seen through our emergency department,” Cook explains. “For the inpatient cases, I would say the case management my team provides largely drives the satisfactory completion of the requirements. In the emergency department, we have a combination of the physician, the nurse, and my team, including a nurse case manager and a social work case manager.”
To educate case management and other staff on these changes to the homeless discharge process, the health system relied on the California Hospital Association’s user manual.
“It gave a brief distillation of the act and its requirements,” Cook says. “It explains how they perceive the requirements should be met.”
Using the association’s manual, Sharp leveraged its technology to improve compliance.
“We’re not in a position where we can bring on more full-time equivalents just because of a new state law,” Cook says. “This reality challenges organizations like us to be at our very best and to demonstrate our ability to think differently by building technology that will make the load easier.”
For example, the health system built an electronic health record that includes information about documents and steps needed to plan the discharge of a homeless patient, he says.
“The case manager and the emergency department nurses see this technology,” Cook says. “There is an automatic prompt or automatic fill. If I’m doing an assessment as a clinician and I answer questions about the patient’s housing status, it could automatically populate this case into the homeless tracking.”
The bill gives the health system a lens for observing distinct populations, an unexpected outcome.
“It began to broaden the ‘a-ha’ moments of ‘This is how you look at it and stratify different populations for true healthcare management,’” Cook explains. “Everything is not just a big old elephant anymore, sitting in the middle of the room. It gives you some insight and comfort level that, yes, you can break down things and they can be made meaningful. You can do a lot in a short order that will make an impactful difference.”
The downside to the bill is that it includes many complex parts. Health system staff may not buy into the change and processes.
“One of the things we found immediately is that we always ask patients about appropriate clothing, especially when they don’t have it or are going without shoes,” Cook says. “We hardly ever documented that before because we didn’t see it as necessary.”
Documentation required by the new law is one of the more challenging aspects, he notes. Nurses take the time to ask homeless patients if they want something to eat, whether it is 5 p.m. to 1 a.m. But when the patient says, “no,” nurses now have to document that they asked. Before, they would move on to the next task.
“We found there were a number of items like that — things we naturally did that we did not think to document, or our clinicians did not document,” Cook says. “Then this bill passes, and you have to write it down. We’re still learning new ways to ensure maximum compliance.”
The discharge planning law also requires screening for infectious diseases. COVID-19 has added a new challenge.
“Not long ago, we had an outbreak of hepatitis that was distinct to the homeless population in San Diego,” Cook says. “We had to check for hepatitis and indicate our findings.”
The bill’s intentions overlap with what large metropolitan health systems largely already do for their homeless patients, he notes.
“We expect there will be more and more of these bills,” he says. “Beyond social determinants of health, homelessness should be treated as a comorbidity.”
Beyond state legislation, if medical professionals treated homelessness as a comorbidity, it could make a big difference in how the public viewed the homeless. It would resemble how public views of smoking changed after smoking was identified as a public health problem, Cook says.
“My hypothesis is we want to stop homelessness, so treat it like a comorbidity,” he adds.
- Wadhera RK, Choi E, Shen C, et al. Trends, causes, and outcomes of hospitalizations for homeless individuals. Med Care 2019;57:21-27.