Homeless patients often arrive through ED

Physician suggests DP role in their care

National reports indicate that cities across the United States are seeing double-digit jumps in the number of homeless people. Likewise, hospitals are reporting increasing numbers of indigent and uninsured people needing care in their emergency departments (EDs).

Cities from New York to Los Angeles have reported increases in homeless people and families of 12% to 40%, according to a report by the Center on Budget and Policy Priorities in Washington, DC.

This means that hospital discharge planners increasingly will need to find ways to provide a safe discharge to the community for patients who do not have homes to which to return.

"In my daily job, I'm encountering homeless patients routinely," says Jennifer Best, MD, an assistant professor of medicine at the University of Washington in Seattle and an associate program director of internal medicine residency program at the University of Washington. Best also is the deputy editor of the Journal of General Internal Medicine, and she's with the hospital medicine program at Harborview Medical Center in Seattle.

Discharging homeless patients is a frustrating process, and often these patients have to be sent back to the streets, because social safety net organizations are overburdened, and there are no alternatives, Best says. So, Best has developed a guide for how to handle these patients.

When Best attempted to find practical recommendations in the literature for how to improve hospital discharges of homeless and indigent patients, she came up short. But she decided to summarize the advice and models that are available in a paper published in the Journal of Hospital Medicine.1

Not all hospitals see as many homeless patients as does the Harborview Medical Center, Best notes.

"But they probably will see more and more," she says. "So, we've developed a quick memory aid for people who may not see homeless patients as much as we do."

Here are some ways hospital case managers, social workers, and others involved in the discharge process can help improve care transitions of homeless patients:

1. Assess their housing status.

"That sounds basic, but if you look at it, hospitals are not required by any agency to collect homelessness data," Best says. "At our hospital, we take care of a lot of these folks, and sometimes that information is cobbled together by self-report — something that's in the chart."

Patients might enter an address for a homeless shelter when they enter the hospital, she notes.

The key is for discharge planners to become aware of which patients are homeless or who have unstable housing, including those who are staying with friends.

"Those who are staying with friends might be just as vulnerable as those living under bridges, which are the people we classically think of as homeless," Best says. "So, this needs to be assessed up front, and someone has to ask these questions."

Be direct: Ask if the patient has a home. If the patient says, "Yes," then ask, "Tell me about that. Who do you live with?" Best says.

If the patient responds that he or she is staying with a friend or has been staying at a shelter, then Best documents the response.

"Some folks who live at shelters have long-term relationships with those shelters," Best says. "For some patients, those are longer-term placements, and they might be there for years and years."

2. Screen for common medical conditions.

The goal is to screen for medical conditions that are common among homeless patients with the goal of preventing disease, Best says.

"The mortality rate of people who are homeless is really high," she says. "Their life expectancy is around 45 years of age, and almost any kind of chronic medical condition, heart disease, lung disease, diabetes, high blood pressure, liver and kidney diseases are at a higher frequency in people who are homeless."

Homeless people also are at higher risk of infectious diseases, including tuberculosis, HIV, and hepatitis, she adds.

"So, you need to be detailed when you first see a homeless patient, even asking them to disrobe entirely," Best says.

"We find that people who've become accustomed to sleeping in shelters don't want to take off their coat or bag," she explains. "Building trust is an important part of it."

When the homeless patient is disrobed, clinicians need to look for evidence of abuse, trauma, and skin conditions, Best says.

Also, hospital clinicians should accelerate homeless patients' vaccination schedules, giving them two doses of hepatitis A and B vaccine before they leave the hospital, she suggests.

"If they're using drugs, then counsel them on needle exchange and screen them for TB," Best adds. "Also talk with them about their substance abuse."

Studies have shown that homeless people who are hospitalized might be willing to quit smoking, and a period of hospitalization could provide a good opportunity for support and counseling about this, she says.

3. Address primary care issues.

Hospital clinicians often focus on fixing acute problems, so thinking about primary care issues is outside their comfort zone.

However, for homeless patients, hospital physicians are their only primary care providers.

"What's interesting is the homeless patients I care for I see again and again and again," Best says. "I do have continuity of care."

So, hospital clinicians should consider checking homeless patients' cholesterol, and they should ask questions about primary care issues, she suggests.

"There should be an expanded role for hospitalists in providing some kind of primary care to people who do not have a primary care physician," Best says. "Make sure they're vaccinated for pneumonia and think about their blood pressure and things that are chronic."

Part of discharge planning could include facilitating screenings and consultations for primary care issues like colonoscopy in an inpatient setting, she adds.

Also, homeless patients with diabetes and diabetes complications need to be handled differently than typical hospitalized patients.

"We see people with skin and soft-tissue infection," Best says. "They have developed diabetic foot ulcer, and it's gone into the bone, because it's been left untreated."

These patients might need long-term antibiotics, and if they were the typical patient they'd be sent home with a nurse. But they don't have a home, and they can't be sent home with an IV line, Best says.

"So we send them to nursing homes," she says. "But if someone has substance abuse issues, nursing homes don't want to take them, and they'll end up in our hospital for weeks and weeks."

While there, clinicians can do a colonoscopy and start to work on their substance abuse issues while they're there, Best says.

4. Provide follow-up care.

The typical discharge follow-up of sending information via fax or phone calls to community providers does not work with homeless patients, since they don't have consistent PCPs, Best says.

"Sometimes you can ask a patient to carry a copy of their discharge summary with their stuff, and they'll go from hospital to hospital," she says. "If they have a discharge summary to show that doctor, then it might help facilitate their care."

If the health care system has after-care or community clinics, then providers can refer homeless patients to these facilities at discharge, she suggests.

"People who don't have a primary care provider might need a quick stopover to check their lab work, follow up on culture results, or to obtain other information that wasn't available at discharge," Best says. "So, we have a clinic where people can come for no more than a couple of visits, but it helps serve as a bridge."

For health systems that do not have access to an after-care clinic, providing follow-up care is more challenging.

"People can come back to urgent care or the emergency room, but it's not ideal," Best says.

Discharge planners need to think about more than the usual type of contingencies and take care of these before the patient leaves the hospital.

Hospital providers need to determine how best to give homeless patients screening tests where the results are not going to be available before they're discharged, Best says.

For example, if the patient is given a standard HIV test, then the discharge process should include a provision that the patient be given the rapid HIV test, where the results can be reported before discharge, or that discharge planners make arrangements for the patient to return to the hospital to obtain the test results, Best says.

Discharge planners also need to ask homeless patients how they might reach them after they leave the hospital, Best says.

"Many homeless patients do have cell phones," she notes. "So, you ask how you can reach them, or if you can call their mental health counselor if anything comes up."

5. Initiate an end-of-life discussion.

"This has to do with the idea that when people come very ill and homeless and have fractured relationships in their lives, then they don't have obvious decision-makers who will decide whether they are put on a ventilator," Best explains. "So, you need to have an honest discussion and thoughts about what you want done if they're critically ill."

Help the patient identify any emergency contacts, including friends, write a do-not-resuscitate (DNR) order if they choose, and identify advance directives, she adds.

"This allows them to have control over their lives," she says.

6. Keep discharge instructions simple.

"Keep them as simple and realistic as possible," Best advises. "Health illiteracy is a real problem for a lot of people, but it really affects homeless patients."

In her research, Best found that half of study participants felt it wasn't possible to follow medical advice at discharge.

"It was quite remarkable," she says. "We overestimate patients' ability to understand what we ask them to do."


1. Best JA, Young A. A SAFE DC: A conceptual framework for care of the homeless inpatient. J Hosp Med. 2009;4(6):375-81.


For more information, contact:

• Jennifer Best, MD, Consultative and Hospital Medicine Program, Harborview Medical Center; Deputy Editor, Journal of General Internal Medicine; Assistant Professor of Medicine, University of Washington; Associate Program Director, Internal Medicine Residency Program, University of Washington; 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 744-3249. Email: jabest@u.washington.edu.