Presentation on theme: "Michael Ferry, LCSW Ada Lopez, MSCED"— Presentation transcript:
1 Medical Respite Care: Helping the Homeless Bridge the Gap Between Hospital and Shelter Michael Ferry, LCSW Ada Lopez, MSCEDYale New-Haven Hospital Columbus House20 York Street Ella Grasso BoulevardNew Haven, CT New Haven, CT
2 Defining Homelessness: Homelessness includes those who areStaying at a shelterStaying on the streets, outside, or some other place not meant for habituationDoubled up with friends or family, or temporarily staying in a motel/hotel AND are unable to return or secure alternate arrangementsIncludes both chronic and transitional lack of housing
3 Homelessness in New Haven Homeless in New Haven: 700 people on averageRobert Woods Johnson study by Kelly Doran, MDStatistics from a sample of 113 homeless individuals:Age (mean): 49 yearsSex: 73% male, 27% femaleInsurance: 75% MedicaidSubstance abuse historyFigures provided by Kelly Doran, M.D.
5 Figures provided by Kelly Doran, M.D. Readmission RatesOf the homeless patients that were hospitalized:53.8% were readmitted within 30 daysOf these readmitted patients:54% were readmitted within 1 week75% were readmitted within 2 weeksThe collective population of Medicaid patients (which includes the homeless) during this same period had a 30-day readmission rate of 18.7%Figures provided by Kelly Doran, M.D.
6 Figures provided by Kelly Doran, M.D. Timing of Readmission54% within 1 week 75% within 2 weeksDays to ReadmissionFigures provided by Kelly Doran, M.D.
7 Medical Respite Programs A literature review found that they:Improve care delivery and health outcomesDecrease future Emergency Department visits and inpatient hospitalizationsDecrease length of stay and costsAllow for the opportunity to connect patients with supportive housing and other services to break the cycle of homelessnessInformation provided by Kelly Doran, M.D.
8 Description of the Medical Respite Program at Columbus House Shelter Location: Third floor of Columbus HouseNumber of Beds: 12Funding: Pilot grant from the State of ConnecticutLength of stay: Projected to average 21 days, but stays permitted up to 30 daysReferrals: From YNHH inpatient and observation unitsStaffing: 24-hour supervisory staff, Visiting nursing for medical care
10 Learning a Hospital Patient has been Identified as Homeless Self-disclosureConsultation by Medical StaffReview of Documentation:Address and phone fieldsPhysician DiagnosesNursing EvaluationsSocial Work evaluations
11 Eliciting Circumstances of Homelessness “During the past two months, have you been living in reliable housing that you own, rent, or stay in as part of a household?”If yes, “Are you worried that in the next two months you may not have reliable housing?”If no, “Where have you lived for most of the past two months?”“Are you able to return and stay there following discharge?”If yes, “Are you able to receive a visiting nurse there?”If no, will this patient have a post-discharge medical need requiring respite?
12 Approaching Discharge Staff identify an expected post-discharge medical need requiring skilled nursing. The care manager verifies that the patient meets eligibility criteria for the Respite Program. The social worker assesses the patient, introduces the idea of Medical Respite, and obtains approval for a Columbus House patient navigator to interview them via a signed release of information.
13 Medical Eligibility for Respite Care Requires skilled care, such as that provided by a visiting nurse, but not so much as to need a stay in rehab or hospiceAre independent with their ADLsTransfers & ambulates independently, or using mechanical assistance such as wheelchair, crutches or caneAre continent of bowel and bladderDo not require IV hydration. IV treatment is acceptableAre free from influenza or tuberculosisMedical issue is reasonably expected to resolve in 30 days or less
14 Psycho-Social Eligibility for Respite Care Lack suitable housingAre alert, oriented, and psychiatrically stable enough to receive care and not interrupt the care of othersAre cognitively able and willing to comply with treatment requirements, visiting nurses, shelter case managers, etc.Are willing to remain substance-free during their stayIf detoxified during their hospital stay, they must be free of symptoms for at least 48 hoursMethadone patients are permitted
16 Evaluation and Transfer Process The patient is interviewed by the Patient NavigatorUpon approval for Medical Respite, the care manager submits referrals to a local medical clinic (or other designated medical provider) and a home nursing agency.A detailed discharge checklist is used to minimize complications afterwardUpon discharge, Columbus House staff escorts the patient from the hospital to the shelter.
17 Typical Concerns Before/After Discharge Patients are sometimes discharged without all necessary prescriptions/wound care/diabetic suppliesPatients may not have active prescription coverage with which to fill or refill their prescriptionsPrior medications being continued may not be verified as within the possession of the patientThe patient may not not have the resources to secure non-covered or over-the-counter medicationsThe new and/or ongoing medications may not being prescribed in sufficient quantity to last until the patient’s next appointmentPatients are sometimes discharged without a named doctor, occasionally only a clinic, and sometimes only a follow-up appointment with a specialistPrescriptions for Medical Respite patients are sometimes sent to pharmacies other than our Apothecary, sometimes creating delivery/procurement issuesPatients are sometimes discharged without established medical appointments, and are instead being told to make their own appointmentsThe patient’s primary care physician sometimes cannot be contacted, or is unwilling to prescribe prior to an initial appointment
20 Continued Care Weekly Case Review meetings which include Social workers, case managers, and pharmacy from Yale-New Haven Hospital,Staff from the Medical Respite Care program, andStaff from local clinics and home nursing agenciesPatient care, safety, and transitions to additional services are discussedOngoing exchange and tracking of information regarding the identification, progress, and outcome of patients.Ongoing steering committee meetings address systemic issues impacting the program and patient care
21 Preliminary Data From October 7 to April 30: 493 patients were identified as homeless and screened (includes repeat patients)The above screenings resulted in 321 unique patients
25 Preliminary Insurance Numbers… (Includes repeat patients)Covered by Medicaid = 83.4%Covered by Medicare = 15.8%Covered by private insurance = 1.8%No insurance = 9.9%Patients with Medicare or Husky C and thus are either aged or disabled = 37.5%
26 Preliminary Mental Health and Substance Abuse Numbers… Patients assigned a mental health diagnosis, even if not currently experiencing symptoms = 62.0%Patients abusing alcohol: 53.6%Patients using illicit drugs: 54.8%Combining the alcohol & drug numbers, 77.6% of patients were actively abusing alcohol or using illicit drugs, while 22.4% were not misusing either.
27 Preliminary Medical Numbers: (Includes repeat patients)Patients without a Primary Care Provider upon admission = 37.9%Average number of Emergency Department visits during the prior 365 days = 14.2Most common presenting issue = Alcohol Intoxication/Withdrawal (17.9%)Runner-up presenting issue = Chest Pain (10.5%)Most common chronic condition = Diabetes (16.4%)Average number of medications prescribed at discharge = 6.7
28 Preliminary Disposition Numbers… Out of 474 discharges (includes repeat patients):50 patients were admitted to Medical Respite (10.5%)32 patients went to a skilled nursing facility (because their needs were more than could be managed at Respite) (6.8%)93 patients had family or friends willing to take them in (19.6%)155 patients went to standard shelter services, due to not meeting criteria (typically due to lack of a medical need requiring recuperation) (32.7%)61 patients declined respite or shelter services choosing the street instead (12.9%)37 patients identified as homeless had a residence or acquired housing at discharge (7.8%)38 patients went on to other forms of care, e.g. inpatient psychiatric or substance abuse treatment (8.0%)8 patients could not be included, e.g. due to rapid discharge or demise (1.7%)
29 Initial ImpactAverage number of Emergency Department visits during the prior 365 days = 14.2, for all screenings12 of 26 Medical Respite patients (46%) who completed the program returned to the Emergency Department at least once following discharge from the program8 of 26 patients (31%) that completed the Medical Respite program returned to the hospital within next 30 daysAnnualized rate of Emergency Department visits following discharge from Medical Respite = 7.7 visitsExcluding our most unusual outlier patient, the annualized rate of Emergency Department visits following discharge from Medical Respite = 4.6
30 RecommendationsComprehensive training regarding the program and identification/referral of homeless patientsThorough assessment of patient ability and motivation for self- care/medical complianceMarketing materials for patients unfamiliar with or reluctant to return to the shelterComprehensive treatment plan prior to discharge, with special attention to insurance and medicationsOngoing and open channels of communication re:ReadmissionsProgress/obstaclesSafety issuesWeekly multi-disciplinary team case review and planning meetingsThorough investment and cooperation from home nursing agenciesMedical review of challenging/recurring casesOngoing data collection