Discharge Planning Advisor
Innovative program helps homeless, frees up beds
Collaboration among competing health systems
An unusual collaboration among three competing California hospitals is providing much-needed post-discharge care for homeless people. It is linking those individuals to ongoing medical benefits while freeing up hospital beds for more acute patients.
Establishment of an innovative homeless shelter — where people who need care after discharge are allowed to stay 24 hours a day — came about after representatives of homeless services in the community asked to talk with hospital officials about homeless people who were being discharged from the facility but still needed follow-up care, says Kate Tenney, RN, manager for case management at Sutter General Hospital in Sacramento, CA.
"In California, if you are going to have home care, you have to have a home," Tenney adds. "They won’t see you on the street or in a car. Homeless people who had no address and no physician were showing up at shelters with dressings that needed to be changed."
When Sutter case managers met with the advocacy groups, which included the Salvation Army, they brought along case managers from two other major hospital systems, she says. "We decided that what we needed were shelter beds where patients could stay 24 hours a day or could come there and get services during the day."
To establish what is known as the Interim Care Program, each of the hospital systems donated $50,000, and the state of California contributed $150,000, Tenney says.
The program, which uses beds located within the Salvation Army of Sacramento facility, opened in April 2005, has a capacity of 18, and averages about eight to 12 patients a day, she adds.
The managers of the three hospitals’ case management departments serve as permanent board members, Tenney notes. They represent the sponsoring hospital systems, which in addition to Sutter Health include Catholic Healthcare West and the University of California-Davis Medical Center.
Also represented on the board, she says, are the Salvation Army, the California Department of Assistance, and MAAP, formerly the Mexican American Alcoholism Program, which is a foundation established to promote the welfare of California’s Latino population.
"When our individual case managers have a patient they think would benefit from the program, they run it by someone on the board, and the nurse on the project looks over what the patient will need," Tenney explains.
"For case managers who normally have to see patients discharged to the street knowing they will come back with an infected wound, it’s very positive to know we can put them somewhere safe," she notes.
Only individuals with a medical need — such as keeping a leg elevated or having a dressing changed — are allowed to stay in the 24-hour shelter, Tenney says, noting that homeless shelters normally are open only at night. "We have been very conservative about who we send there — we didn’t want anything to go wrong."
A part-time nurse makes sure the patients follow physician orders, keep their wounds clean, and get to their scheduled appointments, she notes.
One recent shelter patient was an 18-year-old whose family lives on the river. She had broken her leg. Only the girl stayed in the shelter, because the rest of the family didn’t need to be there, Tenney says.
The program has been particularly helpful, she points out, for homeless patients who are in need of surgical procedures but otherwise wouldn’t have them because of concern by physicians that they had nowhere to recuperate and couldn’t take care of themselves afterward.
"This turns out to be one of the biggest benefits, and one that we had not anticipated," she says. "We were not aware that people weren’t getting procedures done because they had no safe place to go. Now they can actually have the surgery."
"There was one gentleman — in his 40s and with an alcohol problem — who was hit by a car a number of years ago and needed to have pins removed and reconstruction done to both ankles," Tenney adds. "He had needed [the surgery] for a while but had to be able to do dressing changes, because an infection could have made him lose his legs."
"He came in and said the physician wanted to do the surgery if he could get into the interim care program," she says. "I saw him a few days ago, and he was up and around. Home health [nurses were] coming by [the shelter] to give him wound care and intravenous antibiotics."
Without the support provided by the shelter, notes Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health, the man "never would have had the surgery, or would have had it and been stuck in the hospital, [becoming] someone who could not be discharged and would be staying for free."
In addition to preventing the financial shortfall that results from the hospital stay of a nonpaying patient, she says, "[the program] opens up hospital beds that we otherwise would not be able to place patients in."
Having the option of referring patients to the Interim Care Program helps prevent the misunderstanding and resentment that can occur when homeless people are returned to a shelter after receiving treatment in the emergency department (ED), Tenney notes.
"A lot of times, homeless patients come into the ED with multiple problems but are there for one particular thing," she explains. "We deal with that one thing, and then they are back on the street. When they end up back at the shelter, the [shelter managers] believe we’re just dumping them without taking care of their problems."
The misunderstanding is that they mistakenly believe that all health care is provided in the hospital, Tenney adds. "The community expectation is that when [the homeless person] comes into the ED, we take care of everything."
Her explanation of the situation during the initial conversation with the homeless advocates led to their asking Tenney to get involved in devising a solution, and ultimately the group began meeting on a regular basis, she says.
Expanding the mission
Although the program was designed for people who need follow-up care after hospitalization, it has been expanded to include ED patients who don’t need to be in the hospital, Tenney adds.
"In the past," she says, "with the logistics of the homeless, the only real access to care is through the ED. If [they] call the doctor’s office and say, I need to come see you,’ if there’s no insurance, the likelihood is they’ll be turned away.
"If they go to a community clinic," she continues, "they’ll be put in line with everyone else who needs a procedure, and it might be a long time before they get what they need. The simplest way of accessing care has been to wait until they’re very ill and walk into the ED."
Another benefit of the interim care shelter is that it provides linkages to community resources that the patient otherwise wouldn’t have known about, Tenney says, "like finding a primary care physician or a drug rehab program or getting into a clinic for ongoing medical care and getting that funded."
For some of the homeless patients, many of whom don’t have insurance, staying at the shelter provides the opportunity to qualify for Medicare or Medicaid, she adds.
Individuals who are homeless typically "have some sort of addictive personality or substance abuse problem, usually an alcohol or drug problem," Tenney points out. For that reason, she says, they are very resistant to anything that will permanently take them off the street.
"For someone with a chronic disease to go into a facility, they have to sign over their resources to that facility forever, which eliminates the ability to go out and buy a fifth of whiskey every other day," Tenney notes. "Decisions are made around that, so they are not willing to give up their freedom. They avoid the health care system and only come in when they are very ill."
Such people rarely take the medications they are prescribed, she says, either because they don’t understand the purpose or because they sell them on the street.
Getting these individuals connected to a clinic that can provide ongoing care "teaches them what it’s like to have health care, to seek care on a regular basis," Tenney adds. "When they do that, an illness doesn’t get as serious as it otherwise might."
Because they have never before been involved with the health care system except in an emergency, many of the shelter clients need guidance in accessing care, Leach explains.
"It’s a real learning experience," Tenney adds. "These are people who don’t even know how to ask the questions. [Staff at] places like the Salvation Army are much better at speaking their language, which is a crucial part of it. They translate after we tell them what the medical needs are, and then they tell the patients how to go about getting those needs met."
The aspect of the program that is of most concern at present is obtaining the funding to continue it when the initial allocation comes to an end in April 2006, Tenney says. One of the challenges has to do with measuring the initiative’s effectiveness, she notes.
"We have to come up with some way of showing success," Tenney says. "We don’t know what that looks like. Is it a certain bed capacity, the fact that it’s still running? We’re not quite sure what we will use."
Originally, the idea was to keep track of the hospital days saved when a person is at the shelter instead, she adds, "but there’s not a real correlation between a stay at the homeless project and a stay at the hospital. A lot of the [shelter residents] we wouldn’t have kept in the hospital."
Another possibility, Tenney notes, is to look at the cases in which a person initially was unfunded and classified as self-pay, and then on the next visit was on Medicaid. Because the federal government gives money to the state to affect homelessness, she adds, another way to measure success might be to take credit for getting people off the street.
"The California Hospital Association has a grant for putting together a data collection database that we are going to try to apply for," Tenney says. "We’re hoping that if we get that, we will have an experienced person put together a measurement [tool]."
She points out, however, that saving money and reducing lengths of stay were not the motivating factors for Sutter Health’s part in the project.
"Sutter has a mission to provide charity care, and that was our main reason for participating," Tenney adds. "It was not so much [about] cutting back on care but to be active in the community."
One of the things that makes the project unique, Leach points out, is that it involves the collaboration of three competing hospitals. That kind of cooperative arrangement is particularly difficult in the state of California because of laws designed to prevent monopolies from forming, she says. "It’s exciting because there are no such laws around [projects of] community benefit."
"It’s made the case managers involved feel that we are doing incredible work, with outcomes we can see with our own eyes," adds Tenney. "The fact that we can come together like this and collaborate in the community has made this one of the most fulfilling situations I’ve ever seen in health care. It’s been a great experience for all of us."
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