Download Discharge? - National Health Care for the Homeless Council

San Francisco Medical Respite:
Defining a Successful Discharge
Michelle Nance, RN, NP - Midlevel provider
Michelle Schneidermann, MD - Medical Director
Shannon Smith, RN,MS,CNL - Intake Coordinator
Alice Y. Wong, RN,CNS - Nurse Manager
Objectives
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Briefly describe the San Francisco Medical
Respite Program
Describe measures of success respite programs
can use when evaluating discharges
Describe the internal and external philosophies
that influence discharge from medical respite
Learn to identify and incorporate hospital and
community needs into discharge planning
Mission Statement
The mission of the Medical Respite Program is to provide
recuperative care, temporary shelter, and coordination
of services for medically and psychiatrically complex,
homeless adults in San Francisco.
Values
We believe that:
 Every person has the right to housing, health care, and
food security.
 All people have the right to self-determination.
 Every person is valued and entitled to dignity and
respect.
 Homelessness is the result of a complex set of
circumstances and necessitates a multifaceted approach
toward resolution.
 A dedicated team can have a positive impact on the life
of individuals and the community.
Vision
Our vision is to:
 Encourage healing and stabilization by providing respite from
homelessness;
 Provide individualized assessment of client needs and a
comprehensive plan of care;
 Advocate a harm reduction model to decrease the negative
impact of unsafe behaviors;
 Provide compassionate, nonjudgmental, interdisciplinary, and
state-of-the-art care;
 Collaborate with local entities to coordinate provision of care,
options for housing, and initiation of entitlement process; and
 Forge relationships with local, regional and national networks of
those who serve homeless persons.
The Vulnerable
& Medically
Complex
Homeless in SF
SF Homeless Demographics
San Francisco Homeless Count 2007
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Done by SF Human Services Agency, March 2007
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African American/Black 47.6%
Caucasian 43.4%
Male 80.2%
Female 19.4%
Transgender 0.3%
Sheltered Homeless
Transitional Housing and Treatment Centers
Resource Centers and Stabilization
Jail
Hospital
Unsheltered count
Total Count: n=6,377
Health and Homelessness
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The average life expectancy of a homeless person is 4252 yrs (average in US is 80 yrs)
Homelessness magnifies poor health
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Exposes people to communicable illness and trauma
Complicates management of chronic illness
Makes health care harder to access
Homeless patients are more likely to be seen in ED and
admitted and have longer LOS than other patients
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Salit, S. et al (1998)
The Hospitalized Homeless
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Treatment plans that make sense for housed
patients don’t work for homeless patients
No bed for bed rest
 Difficult to keep wounds clean
 Adherence to meds and appointments suffers
 Impossible to follow diet and exercise
recommendations
 Often have no support system to help with
treatment plan
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Hospitalized Homeless:
The San Francisco Experience
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Around 20% - 30% of patients admitted to San
Francisco General Hospital (SFGH) are
homeless
Most of those patients are chronically homeless
Safe and effective discharge plans are difficult to
construct
What Respite Offers
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Successful resolution of acute conditions and
stabilization of chronic conditions
Linkages to additional services
Development of plans focused on positive longterm changes
Recuperation from not only physical illness, but
also the emotional distress and isolation that
accompany homelessness
Demographics of SF Medical Respite
Program
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Ethnicity (and Gender):
Reflect homeless
population of San
Francisco
Gender: 80% male/20%
female
Asian/PI
2%
AI/Alaskan
Native
2%
Latino/a
12%
African
American
36%
Other
2%
Filipino/a
1%
Multiple
Ethnicity
0%
Caucasian
45%
San Francisco Hospitals
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The Medical Respite accepts clients from 10 area
hospitals.
San Francisco General Hospital and Trauma Center
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300+ bed acute care public hospital including only Level 1
Trauma Center in San Francisco area.
Nine other community hospitals
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Total: 2,200 Hospital Beds
Referring Hospitals
CPMC Davies
2%
CPMC Pacific
Campus
2%
St. Luke's St. Mary's CPMC
1%
1%
California
0% Kaiser
0%
Other
1%
St. Francis
2%
VAMC
5%
UCSF
5%
SFGH
81%
Note: Other clients came from outpatient surgery and
DPH case management programs
Discharge Venues in San Francisco
Permanent Housing
 Direct Access to Housing (DAH)
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Supported (may include SW, CM, RN)
Single Room Occupancies (SRO)
Non-supported
 Supported (may include SW, CM, RN)
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Apartment/ House
Discharge Venues
Shelter System
 GA Shelter Bed: 30-90 days
 A Woman’s Place shelter: up to 6 months
 City shelter: Case management; up to 6 months
 City shelter: No case management; 1 week
Discharge Venues
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Higher Level of Care
Board and Care
 Long Term Care Facility
 Emergency Department/ Inpatient Services
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Residential Treatment
Hospice
Discharge in the Literature
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Zerger, S (2006): Discharge standard of practice
is that a client’s primary admitting diagnosis has
been stabilized prior to discharge
RCPN practice models state a safe discharge
from respite care entails follow-up services
Program Measures of Success: Short Term
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Completion of treatment plan, including
demonstrated independence with self-care and
medication management
Improved living situation after discharge from Respite
Engagement with primary care and specialty care
Linkages to social services, benefits
Referrals to mental health and substance abuse
services
Medical Treatment Plan Completion
Left or discharged
prior to completing
treatment
35%
Completed
Treatment
55%
Discharged to a
Higher Level of
Care
10%
Treatment Plan
Treatment Plan Completed!
Length of Stay by Days and Disposition
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Disposition
Mean (Days)
Median (Days)
All Respite Clients
40
28
AWOL
14
5
AMA
17
11
Supported SRO
76
73
Non-supported SRO or Shelter
32
21
Completed Treatment Plan
55
47
Did Not Complete Treatment
Plan
17
10
Discharge Disposition
Violent Behavior
4%
AMA
9%
Inappropriate
behavior
3%
Police Custody
2%
Self Care
51%
AWOL
18%
ED
10%
Long Term Care
1%
Medical Detox
1%
Hospice
0%
Residential
Treatment
1%
Linkages Made at Respite: Medical Services
80.0
70.0
73.7
67.7
All Clients (n=421)
Percentage of Clients
minus AMA/AWOL (n=308)
57.8
52.7
60.0
50.0
40.0
30.0
15.2 15.6
20.0
9.5 10.7
8.6 9.1
10.0
10.7
2.1 2.6
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11.4
Linkages Made at Respite:
Social Services
80
71.7
67.2
70
Percentage of Clients
75.6
62.7
All Clients (n=421)
minus AMA/AWOL
(n=308)
60
50
40
30
32.8
25.9
23.3
23.7
20
10
0
Permanent Housing
Identification card
Income benefit
Medical coverage
benefit
Internal and External Philosophies
External Philosophies: Hospital
“Enormous amounts of energy are spent restabilizing many of our homeless clients. Rather
than successful long-term management we
frequently are only treating acute exacerbations
of the chronic conditions. Respite has been able
to provide stability and management to many of
our clients.”
- SFGH Attending Physician
External Philosophies: Hospital
“We’d love to see people get into housing, especially the
frequent flyers. However, we want to be able to refer
more people and there is often a wait for a bed. So we
can’t refer to you [Respite] if you do not discharge
clients to shelter, as there are not enough beds.”
“The perfect discharge would have them go into some
type of housing, an SRO. Transition back into the
community in some sort of living situation, rather than
back into the streets. But I know we don’t live in a
perfect world.”
-SFGH Discharge Social Workers
External Philosophies: Community
“Our homeless clients, in general, use our ambulances and
EDs much more frequently than the typical housed
client. In addition to overburdening the emergency
medical service, this care does not address their longterm needs. They need access to regular medical care
and medications, stable housing, psychiatric and
substance abuse services, case management…The ideal
scenario would be to establish all of this prior to their
discharge. To give them a solid network of support.”
-San Francisco Paramedic Captain
External Philosophies: Community
“We have few expectations of what you do for
clients because we assume they don’t have
anything. What we like about Respite is at least
their medical linkage is done.”
-SF HOT (Homeless Outreach Team) Case Manager
Referral Difficulty
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Inpatient teams often express the enormous
pressure they are under to discharge their clients.
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“We need to discharge today”
Referral Difficulties
Inappropriate referrals lead to difficult discharges
 Need higher level of care than indicated
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Incontinence, dementia, not competent, not able to
care for ADLs
No acute medical need but a number of comorbidities needing longer-term management
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What is the end point for discharge?
Internal Philosophies
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Multidisciplinary staff:
Nursing, midlevel providers, MD
 Administration
 Social workers
 Paraprofessional staff (medical assistants, health
workers)
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How do we define a “good” discharge?
How do our internal philosophies match our
stated mission?
What Is a “Good” Discharge?
“Our biggest discharge issue is the lack of available,
affordable quality supportive housing.”
– John Wiskind, LCSW
“In reviewing “success,” we look at whether people are
still housed a year later.”
– Mark Hamilton, MSW
“Individual housing is the gold standard”
– Cindy Lee, RN
What Is a “Good” Discharge?
“Completing the acute medical need, but that’s balanced
with the need to more permanently offload burden
from the emergency services and hospitals.”
– Michelle Nance, NP
“Completion of acute medical condition without being
readmitted into the hospital.”
– Shannon Smith, RN
What Is a “Good” Discharge?
“A bad discharge is when we have to call the police. A
good discharge is when we have done all we can do for
someone.”
– Jeanne Andaya, MEA
“The acute medical need is done.”
– Tae-Wol Stanley, NP, Program Director
“The medical need is done, they are started with linkages,
and discharged with reliable follow up”
– Alice Wong, RN, Nurse Manager
What Is a “Good” Discharge?
“A good discharge means that while at respite, a patient has
completed his/her treatment plan, engaged in primary care,
learned self-care and medication management skills, and has
begun the process of transitioning into permanent
housing. There are some patients too vulnerable to be
discharged from respite back to the shelter system and a
successful discharge for those patients would include a move
from respite directly into permanent housing. While in my
fantasy world, all patients would discharge into permanent
housing, the real world of limited resources forces us to triage.”
-Michelle Schneidermann, Medical Director
What Is a “Good” Discharge?
“ At minimum: a resolution of a medical issue in an
environment that is less costly and more normalized
than the hospital. Even a short time (10-15 days) of
recuperation that can be done at Respite rather than
inpatient is cost saving. A good discharge is when a
client leaves better equipped to find a next phase of a
residential setting. I’d like to see direct uninterrupted
access to a bed in the system, whether shelter,
treatment, stabilization or permanent housing.”
- Mark Trotz, Director, Dept of Housing and Urban Health
Internal Philosophies
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Staff have different philosophies shaping their
discharge decisions
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Can lead to confusion and conflict for both staff
and clients
Of note: no clients were asked for a definition
of a successful discharge for this presentation
Who Gets Prioritized for Housing?
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Older
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Medically frail
COPD requiring oxygen
Hemodialysis
Terminal or severe cancer diagnosis
Amputation, paralysis
“Tired”
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In our population, 50 years old is old
Done with the “player” lifestyle
Willing to engage
Most unstable/disruptive to system
Heavy Emergency Services use
Pre-Hospital Living Situation
Permanently
Housed
7%
Homeless
Transitional
10%
Homeless
83%
Living Situation at Respite Discharge
Permanently Housed
28%
Homeless
57%
Homeless Transitional
15%
Living Situation
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51% of clients had a change in living situation
for the better
44% of clients had no change in living situation
Is Individual Housing the Gold Standard
of a Discharge?
“What a lot of clients need is a mom and that’s what they
get at Respite: nagging, reminders, family and friends,
increased social interactions, meals. They lose this in
housing.”
– Cindy Lee, RN
“We tend to think of housing as the gold standard, but
for many clients having an individual room doesn’t
work – they decompensate in that situation.”
– John Wiskind, LCSW
Is Housing the Gold Standard?
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Supportive Housing (SH) programs become less
willing to take our clients because the clients are
too sick/disorganized
SH asked to be “hospice lite;” staff gets
overburdened and burned out
Should we prioritize “less sick” clients for SH
instead of the most fragile so there’s more
success?
Are there other options?
Next Steps?
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Creating more communal living situations
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Foster creation of Medical Rest Beds in Shelters
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Smaller group homes with support services
Encouraging community in SROs
For clients who are awaiting housing
Communal living
Medical/social support
Free up Respite beds for acute needs
Get more data
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Who do we really house?
Outcomes for housed
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Objective: 911 calls, hospital readmits, evictions
Subjective: client’s perceived mood, substance use
Next Steps?
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Re-examine our internal philosophies on
discharge
Create more objective measures for who we
hold for housing
Assessment tool
 “transplant waitlist”
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Formalize team discussions of referrals
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e.g., a “tumor board” for housing
Respite Alumni Network
Incorporating These Philosophies
into Discharge Planning
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Identifying when housing IS the gold standard
and appropriate
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Ex: Client is medically complex and ready to engage
Triaging and creating individualized discharge
plans based on medical and psycho-social need
and willingness to engage
Education and understanding that sometimes a
successful discharge does not include a direct,
uninterrupted discharge to housing
Case Studies
Mr. B
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66 year-old man with a long history of asthma,
COPD, asbestos exposure, tobacco and alcohol
abuse, and depression, who was admitted to the
hospital for pneumonia.
X-ray and CT scan of the chest showed large
masses in his lungs
Confirmed to be extensive small cell lung cancer
Started on chemotherapy and transferred to
Medical Respite 6 days later…
Mr. B: At Respite
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Admitted on January 31, 2008 for assistance
with follow-up chemotherapy treatment and
appointments
Stayed at Respite for 78 days until discharge into
Supportive Housing
Stopped drinking
Reconnected with his daughters in OK
Mr. B: After Respite
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Came back to visit and showed us pictures of his
granddaughters after a visit to see his family in OK
Had last day of chemo and decided to celebrate
Relapsed for 9 days when his case manager finally
found him
Was admitted to a detox facility
Returned to supportive housing
January 2009: entered hospice care
March 2009: Mr. B died in hospice
Mr. M
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33 year-old man with a history of poorly controlled
diabetes, polysubstance abuse, depression, posttraumatic stress disorder, schizoid personality disorder,
admitted to the hospital for DKA.
Immigrant from DRC
History of being boy soldier, imprisonment, and
torture
Poor adherence to insulin regimen
Admitted to Respite for stabilization of blood glucose
levels while awaiting follow-up appointment with
primary care provider
Mr. M: At Respite
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Challenges
Cultural Issues
 Complex psychiatric history
 Brittle diabetic
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Behavior at Respite
Compliant with medication regimen and medical
needs
 Patient split between professional and
paraprofessional staff
 Threatened to kill a Respite Worker
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What Would You Do?
What We Did
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No tolerance policy for violence
Partnered with patient’s pre-existing case
manager
Behavioral contract until case manager could
find alternative place
Capitalized on respect for clinical staff to
continue managing his medical need
Case manager was able to secure a 28-day
stabilization room 24 hours later
Mr. C
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52 year old man with history of CHF, CAD, CVA with L
hemiparesis and slurred speech; w/c bound; hidradentitis
suppurativa; microcytic anemia; HTN; Hep B; Hep C. 35 packyear tobacco history; denies ETOH or SA
Left buttock wound with fistula
Staying in shelters and had been unable to do wound care on
own so presented to the Wound Care Clinic.
Was hospitalized for a left buttock abscess and fistula
Referred to Respite for ongoing wound care of the perirectal
area and bilateral buttock and to f/u with PCP for his microcytic
anemia.
Also needed IHSS worker
Mr. C: At Respite
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Respite cannot offer a hospital bed
Was not independent with bathing: required two-person assist
with bathing and wound care
Not always compliant with wound care and hygiene
recommendations
Lost Section 8 housing and wait list was long for ADA room
IHSS worker would be helpful, but needed housing first
Wound began to worsen
Was found with frank blood soaked through clothes and sheets
on bed from the wounds
What Would You Do?
At Respite: Mr. C
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Engaged with Mr. C’s primary care provider
Wound was to extent it needed surgical repair
Even if Mr. C went to housing with IHSS, an IHSS worker could
not offer the kind of care the wound needed
Issues:
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To high level of care for Respite
With the PCP we decided to discharge
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pt’s choice - shelter or hospital for FTT
Agreed to admit to SFGH for FTT
Respite Case Manager recently saw him at SFGH walking in the
halls with a walker!
Mr. A
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62 year old male s/p R hip fracture, hx of
ETOH
Admitted first to Respite and went AWOL the
same day
After 48 hours a hospital search found he had
fallen while acutely intoxicated and refractured
his hip
Readmitted to Respite 1 week later
Mr. A: At Respite
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Engaged with FSA Case Manager
Decreased ETOH intake
Gained weight
Expressed desire for treatment program
Respite challenge: 290 status (sex offender)
Mr. A: At Respite
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Realities of 290 status in San Francisco
No inpatient treatment program in SF takes 290
status
Shelters discharge someone with 290 status
No inpatient treatment program in Alameda
County will take 290 status, either
What Would You Do?
Mr. A
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Medical Treatment Plan completed
Engaged with primary care provider who he
sees when he doses
Went to stabilization room through FSA case
manager
Detox and ETOH treatment plan left to primary
care provider
Ms. L
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84 year old female with history of HTN, Afib,
anemia, and CHF
This was her only hospital admission on record
at SFGH
Admitted to Respite to finish antibiotics for
BLE cellulitis
No family involvement. Her only child and only
sister have both died.
Ms. L: At Respite
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Finished antibiotics
Received wound care
Engaged in primary care through Bridge Clinic
Through ongoing primary care she became more
medically complex and unable to self-manage her
medications
Accepted into supported senior housing in brand-new
building
Ms. L refused this housing stating, “it’s too new.”
Found competent and not conservable
What Would You Do?
Ms. L
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Had 122-day length of stay
Bridged primary care to Curry Senior Center
that provides case management to low income
seniors
Discharged to shelter with case management
through Curry Senior Center
Respite received sad news: Ms. L died at St.
Francis Hospital on May 1, 2009
So: What Is the Definition of a
Successful Discharge?
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No single definition of a good discharge
We have identified two different conceptions of
a good discharge
Client discharges to a specific place
 Client has received services and links to services
during stay
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In your community you have to balance your
external and internal philosophies
Thank You
Questions?