Creating Hospital Discharge Solutions for The Unhoused and Medically Fragile

About the Author:

Chris Cunningham recently completed her five-year term as a ShelterCare board member, serving as the board liaison with the agency’s program participants. She continues to participate as a member of the ShelterCare Public Relations committee, and also is a participant with NAMI’s (National Alliance on Mental Illness) Statewide Policy Advocates.

Nowhere to Go

Bill remembers limping after injuring his left foot, but he certainly wasn’t thinking the worst. The pain continued, and he learned he had a broken toe, and to complicate matters, diabetes. PeaceHealth Riverbend quickly scheduled his surgery to amputate three toes.

The 55-year-old man had recently moved back to Oregon from Georgia, where he had been working part-time in a restaurant and caring for his elderly parents during COVID. He attributes his diabetes to the sugary soda pop he drank in large quantities at his workplace, but he figured it was a better alternative than the large amounts of alcohol on which he had become reliant.

When Bill returned to Eugene, he had nowhere to go and ended up living with an acquaintance. However, he didn’t want to burden him while he was recovering from surgery. So, the social worker at PeaceHealth Riverbend wrote a discharge plan for Bill to stay in a pallet shelter encampment at St. Vincent de Paul on Highway 99.

It’s hard to imagine being discharged from a hospital with nowhere to go, especially when our local social safety net for people who are homeless is fragile. ShelterCare recognized this gaping hole in the healthcare continuum in 2013 and ever since has been providing post-hospital recuperation to people who are medically fragile and unhoused.

While the temporary shelter was safer than the streets, Bill said maintaining a diabetic diet and caring for his surgical wounds was next to impossible. Once a chef, who prepared healthy vegetarian meals at venues like Breitenbush Hot Springs, Bill knew he needed to adopt a diabetic diet as well as dress his surgical wounds. But he didn’t have ready access to a kitchen and running water.

Because Bill was able to walk, bathe himself, administer his own medications, and was eligible for the Oregon Health Plan, he was approved for a room at ShelterCare’s Medical Recuperation Program (SMR) on Highway 99. Each unit has a shower and toilet, a small sitting area, and a microwave and refrigerator. ShelterCare’s 18-bed program is funded primarily by PacificSource and Trillium, both Coordinated Care Organizations for Oregon Health Plan consumers.

Located in a repurposed hotel in West Eugene, ShelterCare’s SMR program has provided Bill, since early 2023, with a warm room, three cooked meals a day, transportation, and case management to help him heal and eventually transition to permanent housing. A visiting nurse stops by to change the dressings on his foot. Bill hopes that access to all these services will strengthen him enough for future employment.

The SMR program staff have also helped Bill establish a relationship with a primary care physician (PCP), who monitors his medications and who early on referred him for physical and occupational therapy, and mental health services. Bill’s fragile condition and acute medical needs have warranted a far longer stay than the average of 60 days, requiring his physician and insurance provider to approve extensions every month.

ShelterCare Provides a Healing Place Post-Hospitalization

Scott Eastman, Short-Term Housing manager at ShelterCare, says about 30 percent of SMR’s participants are on diabetic diets, the result of not having access to nourishing foods, healthcare, and medicine. What’s more, from May 2022 to May 2023, 49 percent of SMR participants had three or more concurrent medical conditions post-hospitalization, including mental health and chronic health issues, substance use disorders, and physical disabilities.

SMR provides case management to facilitate longer-lasting solutions to its participants, including long-term housing. While such efforts don’t guarantee a perfect ending for everyone, some 68 percent of the program’s participants transition to more permanent housing arrangements. “We want to increase their options when they leave,” Eastman says.

“It’s taken a lot of time to fine-tune the process,” Eastman admits. But the care SMR has taken to create collaborative relationships with local hospitals and insurers has paid off.  “Insurers love us because we provide care at a fraction of the cost of hospital care,” he says.

Eastman says there are hidden costs involved in not providing care to people who are unhoused and discharged from the hospital or emergency room. Without post-hospital care, many are readmitted to the hospital, make frequent visits to emergency departments, and experience poor health outcomes—defined as shorter life expectancy, greater use of acute hospital services, and higher mortality and morbidity.

Sadly, across the country, many hospitals do not have policies that adequately address post-discharge challenges for people who are unhoused. Research shows that most people who are homeless are discharged to emergency shelters or to the streets. With few options, it is difficult if not impossible to clean wounds, prevent infections, get restorative sleep, and eat nutritious meals.

Housing is Healthcare

Bill is one of thousands of unhoused people who can’t rely on a safety net after an acute medical episode.

Research published by the National Center for Biotechnology Information notes an increase in hospitalizations among the unhoused population. Although the reasons for the increase are not known, speculation suggests that an aging homeless population and a lack of access to preventive care may be two contributing factors.

Recent legislation in Oregon emerged following the death of a Salem woman who didn’t have a place to go after her discharge in winter, 2022. Seeking a change in the current state system are three Oregon elected officials: Senator Deb Patterson, a Democrat from Salem, Senator Kayse Jama, a Democrat from Portland, and Representative Paul Evans, a Democrat from Monmouth. This year, the senators introduced Senate Bill 1076 which would require hospitals to have specific procedures for the discharge of homeless patients.

The bill received mixed support, Patterson writes, but a broad coalition supports another bill, SB 1079, that has established a Joint Task Force on Hospital Discharge Challenges to address the issues that hospitals face when trying to discharge patients to appropriate post-acute care settings. A broad coalition of stakeholders, including the Oregon Association of Hospitals and Health Associations, supports SB 1079, which has until November 1, 2023, to submit administrative changes to the governor that do not require legislative actions.

According to the National Institute for Medical Respite Care, SMR’s program is one of two programs in Oregon—the other is in Portland—that provides safe emergency shelter for people who are experiencing homelessness and have been discharged from the hospital following an acute medical episode that necessitates additional time and care to heal. Across the country, some states do not have any post-discharge options, typically referred to as medical respite, medical recovery, or medical recuperation programs, and offer varying services. In the meantime, SMR will do what it can to assuage the conditions for unhoused people, like Bill, who are leaving hospitals in Eugene/Springfield, and to provide an environment that lends itself to improved health outcomes and enhanced well-being. Bill grants that his extended SMR stay has played a significant role in his healing. “I’m grateful for the ShelterCare program,” Bill says.

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