Guest Commentary: Hospitals help ground frequent ER patients

Most of us ignore the homeless at their own peril. We may drive or stride by them without penalty.

Yet imagine that every time a homeless person ambled across your path, you were required to bathe, feed and administer medical care until their general health was restored. Not doing so would subject you to a hefty fine or even criminal prosecution. Moreover, once you finally sent them on their way, leaving them where you found them would be publicly denounced.

It would be madness if individuals had to bear this burden. However, this is the reality faced by the nation's hospitals. Federal law requires they treat any homeless patient who enters their ER. And as officials with Kaiser Permanente and other hospital operators learned earlier in this decade, leaving a homeless patient in front of a shelter upon their discharge can make them a target of public ridicule for "patient dumping."

This places hospitals in both a moral and a fiscal bind. They must treat homeless patients, but those inured to the street life are so chronically ill they wind up in the ER regularly. Research by a homeless organization in Boston concluded that just 119 homeless individuals clocked nearly 19,000 ER visits over a five-year period--at a minimum cost of $1,000 per visit. That leads to some staggering math.

Some hospital managers have decided finding permanent housing for the homeless is cheaper than providing them with continual care. In Denver, where there are more than 1,000 chronically homeless, some of the hospitals have worked with local social service agencies to provide them efficiency apartments.

This has had mixed results. Many homeless persons are mentally ill and can't bring themselves to be inside all the time. Moreover, our political environment frowns upon giving homeless people something everyone else must work for. And of course, there are far more people in need of apartments than there are available units.

To its enormous credit (and nearly as enormous public benefits program), Kaiser has not acquiesced on the "frequent flier" issue. It and other hospital organizations have helped fund a unique concept. After discharge, homeless patients are transitioned into "recuperative care," where they're monitored 24-7 by nurses and case managers. During their stay, social workers connect them with services and benefits they wouldn't otherwise enjoy because of their want of a permanent address.

The first pilot project was launched in 2008, with recuperative care provided at a homeless shelter near Los Angeles, and ended in March with mixed results. The recuperative care patients were vying for resources with hundreds of other homeless people at the shelter. The 30-day average length of stay was considered too long by some of the participating hospitals, which foot the costs to house the discharged patients.

A second program launched earlier this year in Orange County is operated by the Illumination Foundation in conjunction with an affiliate of the Hospital Association of Southern California. It has fared far better. Discharged patients are placed in a motel, and social workers focus exclusively on their needs. The average stay is less than 10 days--a relatively modest $2,000 cost borne by the hospital. Nearly two-thirds of the patients have housing when they leave.

Paul Leon, the Illumination Foundation's executive director, noted that simply keeping the discharged patients in place for this period of time not only helps restore their health--which may cut down on their frequency of ER visits--but helps them qualify for state disability, Medicare and other programs that can pay for permanent housing and healthcare.

The program expands to Los Angeles County next month, where there will eventually be four locations to help homeless patients recuperate.

Hospital managers across the country should monitor this program closely. It could address a seemingly intractable problem with compassionate rationality--something that gives it a fighting chance to be resolved. - Ron

Editor's note: Ron Shinkman was Los Angeles bureau chief for Modern Healthcare.

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