In medicine, when doctors make really awful mistakes, such as operating on the wrong arm or leaving a surgical sponge inside a patient, we call them "never events" -- as in, these things should have never happened and were completely preventable. But there's another event that should be added to the "never" list: discharging homeless patients to the streets after a hospitalization.
Amidst growing national discussions around hospital readmission rates and strategies to improve the hospital discharge process, one key set of questions has not been asked often enough: What is "home" for our patients? Is it a comfortable house with adequate family support? Is it a fifth-floor walk-up apartment with bad heating? Is it a homeless shelter? Is it the streets?
For Arnold*, discharge to "home" meant a ride to the local shelter. Eleven days earlier, Arnold had emergency surgery for an intestinal obstruction. He was critically ill, on a ventilator and in the intensive care unit. But his real problems started when he was discharged to the shelter with the optimistic plan that visiting nurses would find him and care for his wounds. The shelter provided a place to sleep, but at 7 a.m. each morning Arnold, like all the other shelter guests, had to vacate the building, passing the day walking the streets until he was allowed to return in the evening. Needless to say, the visiting nurses never found him. Four days after his hospital discharge he ended up back in the ER and was readmitted to the hospital for a surgical wound infection.
Arnold's story is not unique. A recent study published in the Journal of General Internal Medicine found that 67 percent of homeless patients surveyed spent their first night after hospital discharge at a shelter. Worse, 11 percent spent their first night after discharge on the streets. We need to stop discharging homeless patients from the hospital to the shelters or streets, because it is dangerous for patients and ultimately costly to the health care system.
Hospitalizations are dizzying, disorienting experiences. After lying in a hospital bed for days, patients are sent home de-conditioned and fatigued. This state of being is harrowing for all patients but downright dangerous for homeless patients. Homeless patients have difficulty obtaining and taking medications, going to appointments and following other post-hospital instructions amidst competing demands for survival. Patients in shelters have it better than those on the streets, but not by much. Unfortunately, despite state and federal laws offering protections against some practices, sloppy hospital discharges of homeless patients continue.
Certainly, some might argue that it is not the hospital's responsibility to solve the social problems of its patients, or that hospitals lack the resources needed to address patients' housing situation at discharge. However, ignoring the issue simply creates more expensive problems in the future. Patients who leave the hospital and are homeless cycle through a revolving door of costly, inefficient and dangerous care from the hospital to the streets or shelter and then back again. Homeless individuals visit the emergency department and are hospitalized at rates up to 10 times higher than low-income-housed patients. Once in the hospital, homeless patients have longer stays and cost on average $2,500 more per hospitalization than housed patients.
Hospitals could be part of the solution by breaking the cycle of homelessness rather than perpetuating that cycle. Ideally, homeless patients would be discharged to supportive housing rather than back to homelessness. Another option is medical respite programs, which have been started in approximately 50 locales throughout the U.S. and have been shown to reduce hospital readmission rates and future hospital days. Such programs provide a place for recuperation and services for homeless patients who are too sick to be on the streets or in a traditional shelter, yet who may not warrant a prolonged hospital stay.
As a start, hospital care teams must know (which means they must ask) about each patient's housing status. Standard procedure nowadays is that every time a patient is discharged from the hospital, a box needs to be checked on the medical record indicating the patient's "disposition." The default option is "discharge to home," which my hospital colleagues and I tick off countless times, day in and day out, as if on autopilot. There is no "discharge to streets" option, and, frankly, it's easier for us just not to think about it. Unfortunately, patients will continue to suffer and return to the hospital for costly care if we continue to mechanically check the "discharge to home" box without thinking -- and caring about -- what "home" really means for our most vulnerable patients.
*The patient's name has been changed to protect his privacy, but the story is true.