Shelter with follow-up care helps homeless

Provides shelter for patients 24-hours a day

An innovative homeless shelter — where people who need post-discharge medical care are allowed to stay 24-hours a day — is freeing up hospital beds for more acute patients and providing ongoing benefits to individuals who typically access the health care system only through the emergency department (ED).

The effort began, says Kate Tenney, manager for case management at Sutter General Hospital in Sacramento, CA, when representatives of homeless services in the community asked to talk with hospital officials about homeless people who were being discharged from a facility but still needed follow-up care. “In California, if you are going to have home care, you have to have a home,” adds Tenney. “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 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 the interim care facility, each of the hospital systems donated $50,000, and the state of California contributed $150,000, Tenney says. The facility opened in April, has a capacity of 18, and averages about eight to 12 patients a day, she adds.

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 — who had broken her leg, Tenney says. Only the girl stayed in the shelter, she adds, because the rest of the family didn’t need to be there. Prime candidates for the shelter are homeless patients who are in need of surgical procedures but otherwise wouldn’t be allowed to have them because of physicians’ concerns that they couldn’t take care of themselves afterward, Tenney explains.

“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,” she says. “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,” Tenney adds. “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, 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.”

“In the past, with the logistics of the homeless, the only real access to care is through the ED,” Tenney adds. “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, 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,” she continues. 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 links to community resources that the patient otherwise wouldn’t have known about, Tenney points out, “like finding them a primary care physician or a drug rehab program, or getting them 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 get qualified for Medicare or Medicaid, she adds.

Getting funded

The aspect of the program that is of most concern at present is procuring the funding to continue it when the initial allocation comes to an end in April 2006, says Tenney. One of the challenges, she notes, has to do with measuring the initiative’s effectiveness. “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 impact homelessness, she adds, another way to measure success might be to take credit for getting people off the street.

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.”

(Editor’s note: Kate Tenney can be reached at tenneyk@sutterhealth.org. Barbara Leach can be reached at leachb@sutterhealth.org.)