It Takes a Village

The Hospitalist. 2011 July;2011(07):

July 1, 2011 | The Hospitalist

Figure 1. Proactive Steps You Can Take to Improve Care Transitions

Recommendations for hospitalists to improve care transitions for indigent patients, gathered from sources for this article, include:

If the hospital doesn’t have a team talking about care transitions, start one.
Explore the possibility of a quality improvement project, such as Project BOOST or Project RED. The next deadline for BOOST applications is Aug. 1 (www.hospitalmedicine.org/boost).
Create a multidisciplinary task force to forge partnerships with primary-care physicians. Find ways to involve them in providing access to indigent patients without placing undue burdens on a few doctors. Find the doctors who are providing pro bono medical care in free clinics or church basements.
Screen for eligibility for all appropriate entitlement programs, and get the applications rolling while the patient is still in the hospital.
Always ask (respectfully) about housing status as part of the patient’s social history. In addition to patients in shelters or on the street, others may be living in cars or “couch-surfing” with friends and families.
Connect with homeless resources, such as medical respite programs, now in 60 communities with 15 more under development, according to the National Health Care for the Homeless Council of Nashville, Tenn. (www.nhchc.org). Programs rotating medical residents through homeless healthcare services have also been shown to change doctors’ attitudes toward homeless patients.¹¹
Avoid generic counseling about exercise or nutrition without first assessing the patient’s living situation and access to needed resources.
Know the costs of medications and their accessibility or barriers for a given patient. Learn how to connect patients with indigent drug programs, or have the hospital provide a supply of needed medications to prevent relapse and readmission.
Partner in more integrated ways with community health clinics and explore cross-referral relationships that work for both parties.
Some hospitals have successfully targeted care transitions for patients with specific conditions, such as heart failure, diabetes or pneumonia. Quantify and stratify the need at your hospital.
Home health agencies can be invaluable sources of support for hospitals willing to meet with them to establish working relationships and protocols for indigent patients.
Floor nurses often know more about readmission risks and patients’ stories than administrators give them credit for. Find ways to regularly tap into that expertise.
Listen to your patients and find ways to include their input in quality initiatives.

Other issues disproportionally impacting uninsured or indigent patients include low literacy, low healthcare literacy, language barriers, cross-cultural barriers, substance abuse and mental health issues, homelessness or marginal housing, transportation barriers, and “social isolation, which also plagues our population and, I believe, places patients at risk, as does depression,” says Dr. Critchfield’s colleague Michelle Schneidermann, MD.

One-third of San Francisco General’s patients are uninsured and 40% have Medi-Cal (California’s version of Medicaid), which basically means they are underinsured.

“California has 19 safety-net hospitals, with 6% of the state’s inpatient beds but 50% of its uninsured population. So that’s what we do,” Dr. Critchfield says. But almost any hospital or hospitalist will see many of the same issues and problems, just not in the same proportions. “These are patients who can be most frustrating to hospitalists, requiring a disproportionate amount of our time,” he says, adding the greatest difficulty is helping these patients understand and follow post-discharge care plans. But if someone is ill enough to need acute hospitalization and is later discharged back to the street, readmission should not be a surprise. “We’ve done that experiment for many years, and we know how it turns out,” he says.

Dr. Schneidermann serves as medical director of San Francisco General’s medical respite program, a 45-bed emergency shelter that accepts homeless or marginally housed patients in need of follow-up care following discharge from any of the city’s acute-care hospitals. Research has shown that the programs can have a major effect on keeping discharged patients off the street, reducing their rates of rehospitalization by as much as 50%.^2,3