Imagine going to the hospital with pneumonia, being eventually discharged, and then having to “rest” on a bench or under a bridge in the cold. Unfortunately, because there are limited recuperative care options for the homeless in Philadelphia, many have to endure physical recovery in the most inhospitable of places, often leading to incomplete healing and eventual readmission to a hospital emergency room.
These patients can sometimes be seen walking down the street, still in their hospital gowns or with their identification wristbands still on their arms. The hospitals have done their jobs in ensuring the patient receives the best care possible in the acute setting, but once that emergent need has passed, there is no longer a requirement or mandate to maintain them in the hospital, and it is neither operationally nor financially feasible for hospitals to do so. In contrast to non-homeless residents, hospitalized homeless patients are typically discharged to the street or to a homeless shelter with limited medical supportive services, despite experiencing post-surgical pain or discomfort. Additionally, their lengths of stay in the hospital tend to be double the span of time for non-homeless patients and with greater risk of an exacerbated physical condition.
This gap in care has been addressed nationally via Homeless Medical Respite (HMR) programs. The Homeless Medical Respite model is designed to provide post-acute care for patients who are not ill enough to be in a hospital, but too ill to fully recover on the streets. Because many of these patients tend to have behavioral health needs, HMR’s can also provide care coordination support to connect patients to additional health options or even social services. Average length of stay for a patient at a Homeless Medical Respite program is determined by medical need and progress on an individual treatment level.
According to the National Health Care for the Homeless Council, there are now approximately 80 Homeless Medical Respite programs nationwide. The format of the respite programs tends to vary from one location to the other – some are based in shelters, some are free-standing community sites and others may be in motels. And because the funding stream to support the model of care is so varied from state to state, a partnership among key community stakeholders is usually the greatest harbinger of success when it comes to a sustainable respite program.
“Nationally, hospitals are taking the lead in supporting the growth of medical respite programs,” says Sabrina Edgington, director of special projects for the National Health Care for the Homeless Council. “Hospitals are able to achieve cost savings by referring very complex patients who no longer need hospital-level care while also meeting goals related to population health, transitional care, discharge planning and readmissions. Additionally, many hospitals are looking to be more engaged in their local communities and medical respite programs are an ideal way to build partnerships.”
In Philadelphia, Public Health Management Corporation in partnership with Depaul House, opened the first Homeless Medical Respite program for the city approximately two years ago. Through generous funding from the City, state, operational investments on the part of both PHMC and Depaul, and fee-for-service payments from local hospitals, the organizations were able to open a small 8-bed pilot HMR. Initial results of the pilot were positive and supported national statistics relating to the impact of homeless medical respite programs: pilot patients were older, African-American males; 62% had chronic health conditions; over half did not return to the hospital within 90 days and the majority were connected to a primary care provider.
David Dunbeck is the PHMC director of homeless and social service programs, and oversees the management of the pilot program. “In my 18 years working in homeless services in Philadelphia, one of my greatest frustrations was seeing homeless individuals on the street, in shelters or cafés, with unhealed wounds or other medical conditions, after being discharged from inpatient settings,” David said. “Often, the only recourse was to return the individual to the emergency room and begin the cycle again. The medical respite provides a better option, which allows these individuals the ability to heal in a respectful, medically-supervised setting. By having this extra tool in our tool box, we can greatly impact their health outcomes, while also building a more trusting relationship to work on their other life goals.”
Lisa Washington is a nurse at the PHMC pilot site and has been a part of the pilot care team since its inception. “I now see what before was invisible to me and others - a culture of the invisible homeless - those who have serious medical and behavioral conditions whose needs are temporarily bandaged, who need more supports than the overworked nursing and case management staff in the hospitals can provide.”
In 2016, PHMC will open an expanded HMR that will include eighteen beds and will serve both men and women.
Though this is a step in the right direction and supports patients who may not have otherwise had a sufficient place to heal, there are no other HMR’s available in Philadelphia to support this patient population despite the need. One of the primary barriers to starting this type of program is the lack of established and sustainable funding. The PHMC/Depaul pilot program was supported via a combination of City funds, in-kind support and fee-for-service payments by referring hospitals.
According to Edgington, “In Medicaid expansion states, managed care organizations are beginning to invest in medical respite programs as a way to keep costs down while improving the quality of care of homeless beneficiaries, many of whom are newly insured. As a result of the increased interest in medical respite care, we've seen a spike in technical assistance requests from communities looking to start or expand medical respite programs.”
Another potential barrier is the systemic acceptance and awareness of a care option which, though growing in recognition is relatively new to the Philadelphia healthcare community in general. Continued education for community stakeholders as well as partnerships between hospitals, primary care medical homes and homeless advocates, will help to ensure a stronger network of recuperative care options for the Philadelphia homeless in the future.