Hospitals seek balance in care of homeless patients

LOS longer than for indigent with homes

While the problem of caring for homeless patients might not be as pressing in rural areas as in their urban counterparts, hospitals throughout the country must come to grips with the challenges these patients pose to the bottom line, experts say.

The bottom line, according to new research data, shows that homeless patients stay longer and cost hospitals more than indigent patients with homes. The challenge is to create a balance between the cold facts of hospital finances and providing the best care possible for the patient.

A recent study by the New York City Health and Hospitals Corporation of almost 19,000 homeless patients admitted to New York-area hospitals between 1992 and 1993 compared the hospital charges and expenses for those patients with 384,000 low-income patients with homes.1

The findings were not promising: Homeless patients stayed an average of 36% longer than indigent patients with homes. What’s more, the extra length of stay alone cost the hospital system an average of $2,414 per homeless patient. Add that to the heavy burden of absorbing the cost of indigent care, and the amount is much larger. The major reasons for the extended length of stay, the researchers say, are legal mandates requiring homeless patients suffering from mental illness to be discharged into a supportive environment.

A shortage of available supportive housing and psychiatric beds means this wait could be months long. Severe overcrowding in city shelters and lack of low-income housing means many other homeless patients are kept in a hospital bed until shelter space becomes available, the report continues.

While federal regulations create bureaucratic bed nightmares that seem hopeless, hospitals can take action to curb the problem. Several public hospital systems, for example, are tackling it aggressively. Public hospitals face more challenges than their private counterparts. They are charged with providing health care to the community at large and are overburdened with the costs of caring for the homeless. But by taking the step of developing health outreach programs, an attempt is made to head off illnesses that land these patients in a hospital bed in the first place.

In addition to the costs of extended inpatient stays, many caregivers say, public institutions have an ethical obligation to ensure unbiased access to basic health care. What’s more, the access should be early, not after homeless patients are in need of hospitalization.

"As the public hospital for the county, we are charged with ensuring access to health care to the community as a whole," says Susan Spaulding, MD, director of the Homeless Outreach Medical Services program (HOMES) at the Parkland Health and Hospital System in Dallas.

A few years ago, Parkland began an effort to improve access to primary care and preventive medicine by opening several small community-oriented primary care clinics (COPCs) throughout the city. The HOMES program and COPCs are funded jointly by Parkland and the city of Dallas.

"The concept is that by bringing primary care into the neighborhoods where people live, it enables the public to easily access the health system and enables us to treat health problems before they become so severe that they require hospitalization or other, more intensive health care resources," explains Spaulding.

Mobility makes the difference

The HOMES program is in essence a COPC for the homeless population of Dallas, she says. "It is basically the same thing, it is just that this one is mobile."

Staffed with a full-time internist and a full-time pediatrician, a clinical psychologist, registered dietitian, three nurse practitioners, three RNs, four social workers, an administrative coordinator, and three health care assistants, the HOMES program operates as a six-site health clinic and also has two 40-foot-long mobile medical vans.

HOMES holds 30 clinics a week at 18 different locations throughout Dallas. Open for three- hour sessions on Monday afternoons, Tuesday, Wednesday, and Thursday evenings, and Friday mornings, the clinics offer well-child checkups, immunizations, acute care, referrals to other programs and social services, adult health maintenance evaluations, STD and HIV screening, acute and chronic disease clinics, and a diabetes education program.

The city started a health program for the homeless about 11 years ago, she says. Originally, the program consisted a nurse practitioner who visited the city’s shelters to provide basic medical care and make referrals to the hospital.

Seven years ago, Parkland took over administration of the program, expanding it to the current level. Now it is one of the system’s COPCs, although the only mobile one, Spaulding says.

Physicians in the HOMES program now can do lab work, such as blood testing, for homeless patients. They have a class D pharmacy on both vans, and the physicians can make referrals to specialists at Parkland’s hospital. "With the move to the COPCs, this was another effort at getting out into the community," Spaulding says.

The hospital system doesn’t keep data on which patients are homeless, so there is no accurate way to gauge the program’s financial impact, but Spaulding says the efforts the HOMES staff makes at preventive care result in fewer primary care visits to the hospital’s emergency department (ED). "The cost of a visit to the HOMES site is much less than the cost of an average ED visit."

The project has a budget of $1.5 million that is split between city funds and Parkland’s operating funds, she says. The hospital system absorbs most of the cost of the care, but she notes that in the past few years, the hospital has been able to lessen its dependence on the Dallas tax base, becoming largely self-sufficient. "That is always a challenge for any public hospital system."

Cooperative agreements an option

Some hospital systems, however, have developed arrangements with existing homeless health programs, which take a slightly different approach to solving the problem of providing care to the homeless. In cooperative agreements, a hospital system provides funds and administrative and clinical support to an organization already familiar with the homeless population and set up to handle that population’s specific needs.

The Health Care Center for the Homeless (HCCH) in Orlando, FL, for example, operates a primary health care clinic, dental clinic, vision clinic, wilderness outreach program, and tuberculosis shelter on an annual budget of about $500,000. HCCH receives about $750,000 in support and in-kind services from three area hospitals: Florida Hospital, Orlando Regional Health Care System, and Central Florida Health Care System. "We also have specialists throughout the community who give us two procedures a year, and we make referrals to them," says Paul McGlone, president of HCCH.

When patients need surgery or hospital admission, the hospitals take the case on a rotating basis. The center has more than 9,300 patient visits per year to its primary care clinic at a cost of about $361,000, or $38 per patient.

By helping homeless people enter the health care system at a primary health care level, the center has been able to treat acute medical problems before they require a hospital admission, says McGlone. By helping them manage chronic conditions such as diabetes and hypertension, the center also has helped reduce visits to area emergency departments, he notes.

Team includes 77 volunteer physicians

The center has a full-time clinical staff of one physician, one nurse practitioner, and a paid dental hygienist to manage the cases in the dental clinic. It is heavily dependent on the specialists and other health professionals who volunteer their services, he says. Primary care clinic volunteers include 43 primary care physicians, five advanced registered nurse practitioners, 22 nurses, and seven front desk (intake) personnel. There are 77 volunteer physicians who provide specialty secondary care, he adds. "We have one retired physician who comes in and works evenings in our primary care clinic 2½ days a week."

A retired dentist also comes in and spends one evening a week seeing patients in the dental clinic, he says. "I think that this is evidence of what can happen when you have everyone working together. You hear a lot about medical centers and hospitals and how competitive they are, but this is an example of [different systems] coming together to work toward a solution."


1. Salit SA, Kuhn EM, Hartz AJ, et al. Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998; 338:1,734-1,740.