Discharge of Homeless Patients Policy

Kristen AndersonLisa CabreraKathryn PughStephanie Wizel

Presbyterian Intercommunity Hospital’s Policy for Discharge of Homeless

Patients

"Patient Dumping"

PIH Policy Update Protocol● Reviewed every 3 years, or as needed

● Any individual, committee, or functional team may propose a

new policy or policy update

o Present new policy at management meeting and email

notification

● Review process

o Final approval: Medical executive committee & board

Signatures of approval: dept. director, dept. medical

director, dept. manager, VP, board of director secretary

For nursing policy, must have CNO’s signature for

approval

Facts❏ Homeless patients were 10 times more likely to use crisis

services and 4 times more likely to require inpatient hospitalization, or access to the emergency psychiatric units, than their housed counterparts (Booth, 2006)

❏ Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorders are one of the most vulnerable populations (Sun, 2012)

❏ A high percentage - as high as 20% are veterans❏ About 42% to 77% do not receive public benefits to which they

are entitled ❏ About 25% are mentally ill❏ 33%-66% of single individuals have substance abuse issues❏ 48% graduated from high school; 32% had a bachelor degree or

higher

POLICY

Patient Assessment 1.1 The patient’s discharge needs and capacity to make decisions will be assessed prior to discharge.1.2 The treating physicians, nurses, case manager, and consulting social workers will assess and document the patient’s needs (food, shelter, substance abuse treatment, etc.) and the mental status of the patient during their clinical examinations or assessments over the course of the patient’s hospital stay. If it is determined that the patient does not have the capacity to make decisions, additional services or referrals may be needed such as referrals for additional cognitive or neurological evaluation, inpatient mental health treatment, outpatient mental health referrals, assistive care, involuntary holds ( 5150), or conservatorship.1.3 The treating physician will determine and document the patient’s readiness for discharge (For example, but not limited to, is the patient medically cleared; what the patient’s medical needs are such as but not limited to medications, follow-up appointments, durable medical equipment and home health services; based on the patient's medical need can the patient be discharged to a shelter or the street.)

Determining Discharge Options

The case management and social work services team will collaborate in the development of the discharge plan for all homeless patients.

2.1.1 A member of the case management and social work services team will discuss discharge options with the patient.

2.1.2 If on-going medical needs are identified, a member of the case management and social work services team in conjunction with the patient’s interdisciplinary team will determine appropriate level of care post discharge (SNF, Home Health, etc.) and collaborate with the patient.

2.1.3 After the physician has determined that mental health care is needed, the social worker should contact a psychiatric evaluation team (PET) to assess the patient.

2.1.4 If the patient is elderly and a victim of abuse, an Adult Protective Services report should be filed. If there is no other discharge option except shelter or the street, the patient should not be discharged until Adult Protective Services (APS) responds to the report. Staff will work with the APS staff and patient to determine the discharge plan.

Determining Discharge Options

2.1.5 If the patient has no medical or mental health needs, the case manager and social work services team will assess if the patient has their own discharge plan or if the patient has family, friends or other contacts that can provide or obtain placement for the patient.

2.1.6 If the patient wants to be placed in a local emergency shelter, a member of the case management and social work services team will contact a local shelter or the Los Angeles County Referral Hotline at 211 to determine bed availability and to ensure the patient meets the criteria.

2.1.7 Once a bed is located, the Hospital to Homeless Service Provider Agency Referral form will be completed by the case management and social work services team and fax to the shelter.

2.1.8 If the patient wants to be placed in a local transitional housing program, a member of the case management and social work services team will contact local agencies to see if patient meets criteria.

Facilitation Process3.1 The patient must be cleared medically, and by psychiatry when appropriate

3.2 A member of the case management and social work services staff should complete the Acknowledgment of Collaborative Discharge Plan form WITH the patient.

3.3 If the patient’s clothing is inadequate for discharge, a member of the case management and social work services staff will provide the patient with adequate clothing such as sweats and slippers before discharge.

3.4 If it is determined that the patient is in need of courtesy medication(s), staff should follow policy in place.

3.5 A member of the case management and social work services team will arrange for transportation services.

3.6 During times the case management and social work services staff are not available, the RN caring for the patient will complete the form and facilitate the process stated above.

Documentation

1.1 Initial assessments, including patient’s capacity.

1.2 Follow-up documentation including the appropriateness for

discharge.

1.3 Discharge location and acknowledgment by patient.

Questions to Consider

Questions to Consider Discharge planning for a hospitalized homeless patient is likely to be complicated, and should be on the forefront of your mind from the moment the patient arrives on your unit. By asking the patient a few simple questions, you can help set them on a path to health success.

➔ Do you understand what your medical problem/diagnosis is? (Do you have an understanding of what your health needs are?)

Even if he/she says “yes”, make sure you double-check. Explain the patient’s diagnosis in clear and simple terms, and have the patient restate what you have said, in his/her own words (teach-back method). A handwritten notecard with basic medical diagnoses and interventions, is a convenient way to help the patient increase his/her health literacy. Additionally, you can give the patient the name, number, and title of a specific person to contact (case manager or social worker), if he/she has a pressing medical issue or concern that needs to be addressed. Many homeless individuals lack the financial means or physical ability to make repeated phone calls to a care provider, therefore it is imperative that the patient have access to an available and reliable medical contact.

Questions to Consider➔ How will you get your prescriptions filled?

Lack of money, health insurance, and credit prevent even highly motivated patients from following through with health care. Don't assume that if there's a clinic in the patient's shelter the medications can be dispensed there--they usually can't. In most cases, you or a social worker will need to arrange for the prescriptions to be filled by the hospital pharmacy or one in the neighborhood. Whatever the plan, discuss it with the patient to double-check that they understand it and that it's practical for them. Similarly, if the patient needs to return for a follow-up visit, ask if they have bus fare or if the shelter provides transportation. If not, try to supply tokens.

➔ Where are you going when you leave here? Or, where will you sleep tonight? Patients who dislike labeling themselves as homeless are unlikely to evade these direct questions. If, instead, you ask for an address, they may give an old one or one that belongs to a friend or relative just to avoid admitting they have no place to go. *** If a new mother gives vague answers to your query about her destination, or if she describes unrealistic plans, enquire further. With teenage pregnancy and homelessness rising, a substantial number of girls have nowhere to take their newborn infants other than a homeless shelter. ***

Literature Review & Changes

Literature ReviewSun, A. (2012). Helping Homeless Individuals with Co-occurring Disorders: The Four Components.

● Main purpose of study: Helping chronically homeless individuals who are afflicted with “Co-occurring Disorders,” COD, one major calling for social workers involves multiple complex and challenging tasks. 4 tasks are taken into consideration.

○ Ensuring effective transition of homeless individuals from institutions into community living

○ Helping them apply for government entitlements and obtain SE○ Linking them with supported and supportive housing○ Engaging homeless individuals in COD treatment, incorporating modified

assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help group

Recommendations: Helping chronically homeless individuals who are afflicted with COD is one

major calling for social workers, they need to be more of an integral part of the

follow-up team. A COD treatment plan.

Literature ReviewDrury, L. J. (2008). From Homeless to Housed: Caring for People in Transition.

Ethnographic, longitudinal study (2 years) looking @ 60 clients’ transition from homeless → psychiatric hospital → discharge into HCP

● Findings:o Only 3 clients stayed on the caseload & remained housed throughout the 2-year

studyo Physical illness, exacerbation of mental illness, substance abuse, legal disputes, and

other problems often threatened residential stabilityo Clients lacked resources to manage these challenges without HCP supporto Supportive housing’s aim → improve care by shifting expenditures from one setting

to another

● Recommendations: o Supportive housing offers an opportunity to link clients with a consistent provider

for integrated primary and behavioral health care - address long standing health needs

Literature ReviewGreysen et al. ( 2012). Understanding Transitions in Care from Hospital to Homeless Shelter: A Mixed-Methods, Community-Based Participatory Approach.

● Main purpose o to understand patients’ experiences of transitions from hospital to a homeless

shelter, and determine the perceived quality of these transitionso also looked at different interventions to increase proper placement and

transition for these patients.

● Findingso Homeless patients perceived suboptimal coordination of transition from

hospital to homeless sheltero Communication between hospital and shelter was often faulty

Recommendations: Improved assessment of housing status, communication between hospital

and shelter providers, and arrangement of safe transportation to improve discharge

safety and avoid discharge to the streets without shelter.

Literature ReviewForchuk et al. (2008). Developing and Testing an Intervention to Prevent Homelessness Among Individuals Discharged from Psychiatric Wards to Shelters and ‘No Fixed Address’.

● The main purpose of this pilot study was to test the effectiveness of a homelessness prevention intervention, following psychiatric admission. The intervention was aimed at preventing homelessness among individuals discharged from psychiatric wards to shelters, who claimed to have “no fixed address”.

● Findings:o The intervention group that was given help to attain housing within 2 days of discharge,

maintained housing when interviewed 3 and 6 months post discharge as opposed to control group ( not help) remained homeless at 3 and 6 months.

o In a larger study in the UK, discharged homeless that received housing and community supports to assist with resettlement into the community. Of the 523 participants, 469 (89.6%) remained housed within the community 5 years after discharge from hospital.

Recommendations: Immediate support and assistance in obtaining housing upon discharge from a psychiatric hospitalization. Also,there is a need for systemic solutions related to income support and job training. Policies related to housing and community start-up costs have the potential to provide timely assistance in finding housing for people who have been psychiatrically admitted to hospital and reduce homelessness.

Recommended Changes● Engaging homeless individuals in COD treatment (Co-

occurring Disorders), incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

● The social workers need to be more of an integral part of the the follow up team.

● Give the patient the name of a specific person to call if he needs to telephone the hospital. Most homeless people lack the funds/means and energy to make repeated telephone calls, so it's important that the first attempts to contact someone pay off.

(Sun, 2012)

Recommended ChangesAssign a qualified community health nurse to facilitate a client’s placement in an HCP or other supportive housing community where the previously homeless client can transition to after discharge and allow close follow-up home visits, ongoing assessments, necessary treatment and provide supportive services & resources to help achieve sustainable levels of independence.

(Drury, 2008)

Recommended Changes● Immediate support and assistance in obtaining housing before discharge

from a psychiatric hospitalization. (Forchuk et al., 2008)

● Improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter. DOCUMENTATION TO BE FOLLOWED UP LONG TERM (Greysen et al., 2012)

● Policies need to be documented and followed up related to housing and community start-up costs as well as local, state, and federal assistance and have the potential to provide timely assistance in finding housing for people who have been psychiatrically admitted to hospital and reduce homelessness. These resources should be made to the patient at/before the time of discharge.

● 43% – 77% do not receive public benefits to which they are entitled to. (Sun, 2012)

QUESTIONS?

References Davis, C. (2012). Health care for homeless people: The role of emergency nurses. Emergency Nurse, 20(2), 24-27. Drury, L.J. (2008). From homeless to housed: Caring for people in transition. Journal of Community Health Nursing,

25(1), 91-105. doi:10.1080/07370010802017109Fader, H.C., & Phillips, C.N. (2012). Frequent-user patients: Reducing costs while making

appropriate discharges.Healthcare Financial Management, 66(3), 98-106.Forchuk, C., Macclure, S.K., Van Beers, M., Smith, C., Csiernik, R., Hoch, J., & Jensen, E. (2008).

Developing andtesting an intervention to prevent homelessness among individuals discharged from psychiatric

wards to sheltersand 'No Fixed Address'. Journal of Psychiatric & Mental Health Nursing, 15(7), 569-575. doi:10.1111/j.1365-2850.2008.01266.xGreysen, S.R., Allen, R., Lucas, G.I., Wang, E.A., & Rosenthal, M.S. (2012). Understanding

transitions in care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. Journal

of General Internal Medicine, 27(11), 1484-1491. doi:10.1007/s11606-012-2117-2Sun, A. (2012). Helping homeless individuals with co-occurring disorders: The four components.

Social Work, 57(1),23-37. doi:10.1093/sw/swr008