Analysis Health Systems

Good Practice: Medical Respite Programs Offer Homeless Patients a Place to Go

Erica Sweeney

Viral cases of "patient dumping" this year have shown that many homeless patients simply have nowhere to go after a hospital stay.

Earlier this year, a video went viral that showed hospital workers leaving a disoriented woman at a bus stop outside a Baltimore, Maryland, hospital wearing only a thin hospital gown and socks in freezing temperatures. And in July, a Los Angeles hospital agreed to pay a $550,000 legal settlement after being accused of leaving hundreds of homeless patients at bus and train stations or on the streets after discharging them.

These high-profile cases of “patient dumping” have shed light on the fact that many homeless people simply have nowhere to go after a hospital stay. The cases, while “horrific,” are actually raising awareness about the growing need for more affordable housing and widespread medical respite care for the homeless, says Julia Dobbins, a project manager at the National Health Care for the Homeless Council (NHCHC).

“People who are experiencing homelessness are not always prioritized in terms of good [hospital] discharge planning,” Dobbins told Rewire.News. “Part of that is because there are not a lot of options for a safe place to discharge them from the hospital. [The cases have] raised awareness about … [the fact that] the shelter or the street is not a humane or appropriate place to do that.”

Medical respite, also called recuperative care, refers to short-term in-patient care for people experiencing homelessness who are too sick to recover on the streets or in a shelter, but are not sick enough to continue staying in a hospital. The programs provide an array of health services and help connect people with other resources, including long-term housing.

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There are only about 70 to 80 medical respite programs around the country; several states—including Arkansas, Wisconsin, and Nevada—do not have any. Dobbins says it’s not enough to meet the need, especially as many programs are seeing more patients with opioid addiction and are struggling with limited housing resources to place homeless people.

A National Problem With Community-Based Solutions

Medical respite is designed to serve the diverse needs of a community and help the most vulnerable homeless populations, including people with mental and physical health issues. Some are standalone facilities, while others operate as parts of shelters, transitional housing, nursing homes, or other facilities.

Programs are designed to provide safe accommodations, environmental services, clinical care, care coordination, wraparound services, and safe transitions from medical respite into the community, according to the NHCHC’s standards.

Research shows that medical respite can reduce hospital readmission and length of stay, which can save health systems money and improve individuals’ health and quality of life.

“For people who are housed, when they leave the doctor or the hospital, they’re typically sent home and told to follow the doctor’s orders: eat certain foods, take their meds at certain times, stay off their feet, get rest,” Dobbins said. “People who are homeless, who don’t have a place to recover safely, are not able to follow those orders.”

As Dr. David Munson, medical director of respite programs for Boston Health Care for the Homeless Program, explained to Rewire.News, there’s a strong business case for medical respite care, as it is a cost-effective way for health plans and hospitals to provide care to homeless people. Ultimately, the service shortens hospital stays, decreases readmissions, and prevents post-operative complications. But it’s currently up to hospitals or private donors to create such programs, as most are funded that way, according to NHCHC.

With the Affordable Care Act and Medicaid expansion in several states, communities are realizing that continuity of care and stable living situations are essential for health, and Dobbins says more managed care organizations are getting involved. Still, there isn’t yet a long-term funding source for medical respite for the homeless, though there is a push across the country to make the service reimbursable by the Centers for Medicare and Medicaid Services, according to Dobbins.

A Growing Patient Group: People With Opioid Addiction

Being homeless with a health condition makes an already vulnerable population even more vulnerable, but several groups face greater risk and are most in need of medical respite. Munson says there’s been an increase in patients with opioid addiction accessing Boston’s 124-bed medical respite program over the past five years.

“Really I think all of the patients that our program serves, given that we take care of homeless folks, would fall under that categorization (of being high-risk),” Munson told Rewire.News. “Folks usually have an acute medical issue going on, and then most folks also have a substance use disorder and some mental illness at the same time, so it tends to be a fairly complicated patient population.”

Munson estimates that people with opioid addiction now comprise about half of the organization’s patients. Caring for them involves ongoing medical treatment, psychosocial support, and linking patients to ongoing treatment, whether it’s residential or outpatient.

Harm reduction, including educating about safe injection techniques and understanding that people are not necessarily ready to stop using when they enter the program, are key elements of medical respite, he said.

“Respite is supporting people through the medical reason why they’re admitted to a medical respite program,” Munson said. “If you want to get started on Suboxone while you’re here or get linked to methadone clinic, we can do that. If you don’t, then hopefully we can manage your withdrawal while you’re here so that you can be comfortable and complete your treatments. We need to kind of be flexible and able to manage or provide whatever the patients really need.”

Smaller homeless health and respite care programs are also seeing more people with opioid addiction. Yakima Neighborhood Health Services in Yakima, Washington, offers six individual apartments for medical respite care for the homeless. The program gives patients a place to detox and offers behavioral health support, case management, daily checks by nurses and other services, says Rhonda Hauff, the organization’s chief operating officer.

“Being able to have some of those folks, the particularly high risk ones, in the respite program has proven to be one of our successful methods,” Hauff told Rewire.News.

Patients with opioid addiction tend to stay a little longer than the 21.5-day average for medical respite, said Hauff. The organization, therefore, lets these patients double up in the respite apartments so that more people can get treatment.

In 2017, the Yakima program provided medical respite to 60 individuals for a variety of conditions, including opioid addiction, pneumonia, cellulitis, and mental health issues. Medical respite provided a public cost savings of $135,200 for mental health stays and $392,400 for rehabilitation stays, Hauff said.

“There are a lot of things that we take for granted when we need people to get healthy, and they can’t do if they don’t have a place to recuperate,” said Hauff. “Our hospitals are bursting at the seams with people that need care. Respite is a very cost-effective way to take some of the burden off for those patients that don’t need that highly intensive care.”

Housing Is a Top Challenge for Respite Programs

At the Phoenix, Arizona-based Circle the City, a homeless health-care organization that has served more than 1,000 people in its 50-bed medical respite program, most patients have some type of mental illness, along with a physical health condition, and many also have drug or alcohol dependence, said Kim Despres, program director of the organization’s medical respite programs and vice chair of the NHCHC Respite Care Providers Network. 

“So, we’re usually treating all three of those when patients come here,” Despres, a nurse, told Rewire.News. “They’re very vulnerable. Many don’t have the connections in the community to help manage that mental illness, don’t know where to go for it, and don’t have people advocating for them.”

Circle the City recently opened a second 50-bed medical respite program in downtown Phoenix. The organization’s programs have “decreased re-hospitalizations, decreased emergency room visits, and decreased costs overall for health plans,” Despres said.

“I have no idea what we did before this was here,” Despres said, wishing more people understood how the program improves patient’s lives.

“People walk out of here with their heads held high and maybe 30 to 45 days of sobriety and feeling good about themselves, having pride, feeling respected and valued.”

Thirty to 45 days is the average length of stay for patients at Circle the City, but most important, Despres says, is that about 65 percent have been discharged to living situations other than the streets or emergency shelters.

As part of the program, case managers meet with patients to identify and eliminate any barrier to getting off the streets, which can include helping to reconnect them with family, finding permanent housing, or locating a transitional living situation, like a drug or alcohol rehabilitation center, she says.

Connecting people with long-term housing or other support after healing from an injury or illness is the ultimate goal of most medical respite programs—but it’s also one of the biggest challenges, according to Dobbins.

“We want to create a system that doesn’t funnel people back into homelessness,” she said.

After discharge from respite at the Yakima program, the organization does a 30-day follow-up to see if patients have been readmitted to a hospital. Hauff said about 30 percent of the medical respite patients were placed into stable housing in 2017. In the past, it was up to 70 percent, but she said the area has lost some affordable housing.

“We have a crisis around housing,” said Dobbins, and the lack of affordable housing is a major barrier in reducing or eliminating homelessness.

“No matter how many services we provide, no matter how much we take care of these clients while we have them in respite, if there is no place for them to live then it’s a cycle that will continue.”

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