When there

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When theres no place like home

• HOMELESSNESS
• An Overview and Effective Strategies for
  Discharge Planning of Homeless Patients

Sponsored by Kaiser Permanente
2330 Beverly Blvd., Los Angeles, CA 90057 (213)
744-0724 www.hhcla.org
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Believe nothing, no matter where you read it, or
who said it, no matter if I have said it, unless
it agrees with your own reason and your own
common sense.

• Buddha

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Goals and Objectives

• The participant will demonstrate understanding of
  the discharge planning role, as well as the legal
  and regulatory responsibilities.
• The participant will demonstrate understanding of
  community resources and the social services
  system.
• The participant will demonstrate understanding of
  the values inherent in the delivery of discharge
  planning services.

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Goals and Objectives (continued)

• The participant will demonstrate understanding
  that assessment is a continuous, ongoing process.
• The participant will be able to formulate
  discharge criteria based upon the assessment
  information.
• The participant will be able to identify
  strategies to reduce avoidable days and delays in
  discharge.

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Mark Casanova, Exec. Dir.Homeless Health Care LA

• Exercise

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Needle Exchange

• Video presentation

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Number of Homeless in Los Angeles

• 82,291 101,000
• 2005 Greater
• Los Angeles Homeless
• Count, 01/12/06
• State of California, Department of Housing
• and Community Development, 1999

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Homeless Estimates by Region
This number excludes the cities of Glendale,
Long Beach and Pasadena, who administer and
operate their own respective CoC.
2005 Greater Los Angeles Homeless Count Executive
Summary
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Regional Homeless Counts and Rates
Institute for the Study of Homelessness and
Poverty, March 2004
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Regional Homeless Counts and Rates (continued)
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Regional Homeless Counts and Rates (continued)
Institute for the Study of Homelessness and
Poverty, March 2004
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Regional Homeless Counts and Rates (continued)
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Homeless Estimates by Service Planning Area (SPA)
Continuum of Care 2005 Greater Los Angeles
Homeless Count Executive Summary
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Countywide Distribution of Shelter Beds by
Service Planning Area (SPA), 2003 excluding
Cold-Wet Weather beds
Institute for the Study of Homelessness and
Poverty, March 2004
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Emergency Shelters by Supervisorial District
2005 Greater Los Angeles Homeless Count Executive
Summary
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2005 Greater Los Angeles Homeless Count Executive
Summary by Gender
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2005 Greater Los Angeles Homeless Count Executive
Summary by Ethnicity
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Los Angeles Homelessness by Ethnicity Summary
of Various Studies
Institute for the Study of Homelessness and
Poverty, March 2004
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Los Angeles Homelessness by Ethnicity Summary
of Various Studies (continued)
Los Angeles Homelessness by Ethnicity Summary
of Various Studies
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Los Angeles Homelessness by Ethnicity Summary
of Various Studies (continued)
Institute for the Study of Homelessness and
Poverty, March 2004
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Los Angeles Homelessness by Ethnicity Summary
of Various Studies (continued)
Institute for the Study of Homelessness and
Poverty, March 2004
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To be loved

• Video presentation

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The Homeless Experience

• Pleace and Quilgars (1997) show that homeless
  persons wait longer than other patients to be
  seen, and that inadequate follow-up and discharge
  are more often made for the homeless.
• In Shiners study (1995),
• the homeless felt that
• staff assumed that they
• had faked illness in
• order to get a bed and
• assumed that they were dirty.

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The Homeless Experience (continued)

• Obstacles to compassion towards the homeless are
• The homeless are seen as non-compliant
• High levels of drug and alcohol dependence among
  the homeless
• Resulting health problems are self-inflicted
• Pleace and Quilgars, 1997 155

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Consumer Survey Results

• Have you ever been hospitalized at a county
  hospital/ Kaiser hospital?
• Yes 61 No 16
• Mark all facilities where you have been
• County USC Medical Center 55
• Harbor/UCLA Medical Center 27
• King-Drew Medical Center 11
• Olive View Medical Center 11
• Rancho Los Amigo 5
• Kaiser Sunset 11
• Queen of Angels 11
• Other Cedars Sinai, White Memorial, Santa
  Monica

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Consumer Survey Results (continued)

• How many times have you been treated at a county
  hospital in the present year?
• 1 3 55.5
• 4 6 5.0
• 7 10 11
• 10 11
• Do you feel that you were informed about your
  discharge?
• Yes 61 No 27

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Consumer Survey Results (continued)

• Do you feel that staff included you in making the
  discharge plan?
• Yes 55 No 33
• How much time did you spend with staff in making
  your plan for discharge?
• No time spent 11
• 5 minutes 27
• 15 minutes 11
• 30 minutes 33
• 60 minutes 5

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Consumer Survey Results (continued)

• If you were homeless at the time of your
  discharge were you referred to housing?
• Yes 11 No 61
• Yes, but refused 11 No beds avail. 5
• Did you receive transportation to the housing
  placement?
• Yes 16 No 66
• Yes, but refused 4

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Consumer Survey Results (continued)

• Did you receive referrals for the following
  services?
• Financial Assistance 0
• Follow-Up Medical Treatment 44
• Transportation 22
• Mental Health Counseling 22
• Food 5
• Clothing 5
• Drug Treatment 11
• Nothing 38
• Were the referrals written for you with addresses
  and telephone numbers?
• Yes 38 No 33

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Consumer Survey Results (continued)

• Were you discharged with
• Proper clothing 44
• Medications 44
• Medical Supplies needed 16
• Proper self-care instruction 22
• Over all how would rate your discharge from the
  hospital?
• Very dissatisfied 5
• Dissatisfied 16
• Neither Dissatisfied or Satisfied 16
• Satisfied 27
• Very Satisfied 11

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In the words of Neil Young

• All these people talking about morality should
  just take a walk downtown. They dont want to go
  downtown, because instantly they see homeless
  people,
• and they dont want to.

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L. E. A. R. N. Model

• Listen with sympathy and understanding to the
  patients perception of the problem.
• Explain your perceptions of the problem and your
  strategy for treatment.
• Acknowledge and discuss the differences and
  similarities between these perceptions.
• Recommend treatment while remembering the
  patients cultural parameters.
• Negotiate agreement.
• American Students Association 1999, pp. 7-8

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No. 1 Maxim

• Discharge Planning begins at admission.

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Initial Discharge Screening

• These questions should allow the discharge
  planner to determine whether the patient is
  likely to need a more comprehensive assessment
• Was the patient independent prior to admission?
• Will this current episode of illness impact the
  patients independence short term or long term?
• Does the patient have adequate informal supports
  to manage any loss of independence?

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Initial Discharge Screening (continued)

• Does the patient have adequate resources to
  provide for post discharge (Hospital, Nursing
  Home, Certified Home Health Agency) needs, such
  as meds, equipment, rehab or follow up treatment?
  (Insurance, Private funds, Medicare, Medicaid)
• If the patient had prior home care services, were
  they adequate? Are they likely to be adequate
  after discharge?

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Initial Discharge Screening (continued)

• Are there any special requirements to assess?
• Is there a different level of care needed and is
  there a different payor because of hospital stay?
• Has this patient had multiple hospital admissions?

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Screening and AssessmentFlow Chart
Community service providers should be prepared to
collaborate with the discharge planner whenever
one of their patients is admitted to another
level of service. Information exchange
is crucial to a successful outcome.
Initial screening can be done by chart review,
patient interview, interdisciplinary team
meeting, available demographic information, patien
t diagnosis and history and other methods. The
purpose of this screening is to identify
patients who will need discharge planning outside
of the routine discharge.
Patient Admission
Basic discharge no needs outside of scripts,
routine follow-up and written discharge
instructions.
Initial Discharge Planning
Moderate discharge planning indicated these
patients may need a home health agency referral,
simple DME, community resource
information and/or referral, outpatient rehabilita
tion and out-patient medical follow-up. It is
anticipated the patient will have only
short-term medical needs. Generally speaking,
they have adequate independence and/or social
supports to be discharged home with minimal
intervention.
Complex discharge planning indicated these
patients may need in-patient rehabilitation,
hospice, dialysis, medically complex home
care, high cost drugs, caregiver respite, LTHHC
program, consumer-directed program, adult home
or nursing home placement, substance abuse rehab
or psychiatric admission. Included in this
group are the un-/underinsured with specific
discharge needs that require more funding, or
those who will have long-term, chronic medical
needs.
Comprehensive Assessment
www.health.state.ny.us/professionals/patients/disc
harge_planning
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High Risk Screening Criteria
Patients who fall into any of these categories
should be targeted for a comprehensive assessment.

• Over the age of 70
• Impaired mobility
• Impaired self care skills
• Poor cognitive status
• Catastrophic injury or illness
• Homelessness
• Poor social supports
• Chronic illness

• Substance abuse
• Multiple diagnosis and
• co-morbidities
• History of multiple hospital admissions
• History of multiple emergent care use
• Anticipated long term health care needs (e.g. new
  diabetic)

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Comprehensive Assessment

• Functional assessment (the patients ability to
  perform ADLs)
• Cognitive assessment, if indicated
• Who are the patients informal supports?
• What are the abilities of the informal supports?
• What is the availability of the informal supports?

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Comprehensive Assessment (continued)

• What is the patients living arrangement? (home,
  apartment, with family, congregate living
  homeless)
• This should include a description of the
  setting, such as stairs to enter, wheelchair
  accessibility, functional plumbing, heat and
  cooking facilities.
• What is the patients understanding of his/her
  illness?
• Is the patient capable of participating in
  his/her own discharge planning? If not, does
  he/she have someone who can represent him/her in
  the process?
• What are the patients goals for discharge?

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Comprehensive Assessment (continued)

• What does the patient need functionally to
  achieve these goals?
• What services might be available to the patient
  to achieve these goals?
• What services did the patient have prior to
  admission?
• Does the patient have a preference for a service
  provider?
• Does this patient have insurance or funds to pay
  for necessary care? If not, what resources are
  available to the patient?

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Comprehensive Assessment (continued)

• Does the patients insurance have a preferred
  provider network?
• Does the patient understand the risks/benefits
  associated with his/her choices?
• Is there a history
• of non-compliance,
• which impacts the
• ability to be
• managed at a
• facility?

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Caring for persons who are homeless

• Clinical recommendations
• To help promote successful treatment, develop an
  individualized plan of care that incorporates
  plans to meet some basic needs as well as medical
  needs.
• Become familiar with what food is available in
  local shelters and soup kitchens before
  suggesting to patients how to restructure their
  diet for chronic illness prevention or care.
• Anticipate and accommodate unscheduled clinic
  visits. Create a drop-in time when no
  appointment is required, particularly for new
  patients. Include some evening appointment times
  to accommodate day workers.

The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
44
Caring for persons who are homeless (continued)

• Avoid prescribing medications likely to have
  significant sedative side effects, unless they
  can be tried initially in a safe environment to
  avoid compromising the patients safety.
• If a patient appears to be emotionally fragile,
  consider using an assistant, even for clothed
  examinations.
• Provide a client advocate to accompany patients
  who are unable to navigate through the health
  care system on their own.

The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
45
Determinants of General Care Non-Adherence in the
Homeless and Potential Enhancements
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
46
Determinants of General Care Non-Adherence in the
Homeless and Potential Enhancements (continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
47
Determinants of General Care Non- Adherence in
the Homeless and Potential Enhancements
(continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
48
Determinants of General Care Non- Adherence in
the Homeless and Potential Enhancements
(continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
49
Determinants of General Care Non- Adherence in
the Homeless and Potential Enhancements
(continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
50
(No Transcript)
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Determinants of Medication Adherence in the
Homeless and Potential Enhancements
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
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Determinants of Medication Adherence in the
Homeless and Potential Enhancements (continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
53
Determinants of Medication Adherence in the
Homeless and Potential Enhancements (continued)
The Homeless in America Adapting Your Practice,
Montauk, MD, American Family Physician, Vol. 74,
No. 7
54
Discharge Planning Guidance

• The patient must be stable for discharge.
• The decision for discharge must be based on
  medical, not financial considerations.
• Encourage the patient (or surrogate) to
  participate in discharge planning.
• Give the patient (or surrogate) written notice of
  the intent to discharge.
• Allow for an appeal of the discharge
  determination.
• Involve Social Work, Pastoral Care, Legal
  Counsel, Ombudsman and the Ethics
  Committee/hospital ethicist, as necessary.
• The Journal of Clinical Ethics, Vol. 16, No. 2,
  Summer 2005

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Resources
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Los Angeles County Resource Card   LA County
Information/Referral Dial 211 or
800-339-6993   Social Services (DPSS) GR
Benefits 800-399-4529 DMV/Identification
800-777-0133 Winter Shelter Hotline
800-548-6047 Social Security Administration
800-722-1213 Drug Alcohol Treatment
800-564-6600 Medical Dental Referrals
800-427-8700 Suicide/Crisis Line
800-235-1191 Mental Health Referrals 800-854-7771
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Victims of Crime 800-842-8467 LA City Housing
Info Hotline [phone] Legal Aid Foundation of
LA 800-399-4529 99 Only Store Locator Line
888-LUCKY-99   OTHER _____________________________
______________ ________________________________
__________   Hearing Impaired (TTD) LA County
800-660-4026   Prepared by
www.hhcla.org
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Resource Packet

• United Way Regional Information Guides
• Useful Websites List
• Reduced Fare Bus Form
• Access Transportation Form
• Reduced CA ID Form
• HIV LA Directory
• Ambulatory Care Resource Guide

• Resource Cards
• 211 Tear-off Pads
• Resource Article Book
• LA County Citizens Guide
• Womens Resource (Red Book)
• Womens Yellow Pages
• GLBT Practical Guide

• Peoples Guide to Welfare, Health and Other
  Services in LA County

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Relationships
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Suggestions for Establishing a Relationship with
Referral Sources

• Go visit the facility or agency.
• Invite them for a meeting at your facility.
• Establish quarterly referral network meetings to
  discuss changes, success, issues, etc.
• Set up a form/forum to communicate.

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Information to share with Shelters

• Shelters report that having more information will
  assist them in ensuring that the best possible
  follow-up care is provided.
• They want to know
• Generally, what treatment is given?
• Who to call with questions?
• What follow-up care is required?

This information is adapted from the Toronto
District Health Council October 2004
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Information to share with Shelters (continued)

• What is the schedule for changing dressings?
• Are there follow-up medical appointments?
• Are there medication schedules?
• Are there prescriptions to be filled?
• Are there special considerations, such as the
  ability to manage stairs or special diets?
• Are there safety and mental health issues?

This information is adapted from the Toronto
District Health Council October 2004
63
Information to share with Shelters (continued)

• Hospital staff may want to consider adding more
  information to an existing form or to finding an
  alternative means of providing appropriate
  information to community agencies upon referral
  of homeless patients.

This information is adapted from the Toronto
District Health Council October 2004
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Guidance for dealing with the Disruptive Patient

• Practice guidelines
• Unit policy
• Community standards
• The Involuntarily Discharged Dialysis Patient
  Conflict (of Interest) with Providers
• Williams and Kitsen, Advances in Chronic Kidney
  Disease, Vol. 12, No. 1, 2005

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Strategies to Improve the Outcomes for Disruptive
Patients

• Simplify treatment regimen
• Provide patient education and feedback
• Establish partnership with patient
• Implement behavioral contract
• The Involuntarily Discharged Dialysis Patient
  Conflict (of Interest) with Providers
• Williams and Kitsen, Advances in Chronic Kidney
  Disease, Vol. 12, No. 1, 2005

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Systemic Strategies for Discharge Planning of
Homeless

• SWAT TEAM
• Multidisciplinary Team with or without physician
  leadership, comprised of a nurse case manager,
  clinical specialist, social worker, pastoral care
  and other ancillary personnel targeting
  identified difficult discharges
• DEDICATED PERSON
• One clinical social worker dedicated to all
  homeless discharges.

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Systemic Strategies for Discharge Planning of
Homeless (continued)

• HOSPITAL-WIDE DISCHARGE PLANNING COMMITTEE
• Multidisciplinary team that meets to review
  particularly difficult patient discharges and to
  examine the outcomes as related to discharge
  actions
• PREFERRED PROVIDER STATUS
• Narrow breadth of referrals to SNFs, so SNFs
  feel that they have a steady stream of referrals
  and, thus, be more likely to accept more
  problematic patients

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Documentation to Reduce Risk with Homeless
Patients

• If its not in the notes/chart, it didnt
  happen.
• Document like you have never documented before.
• Document each facility that was called,
  including date and time, outcome and the name
  of the person contacted.
• Document the patients response to options
  presented.

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Challenges for Providers

• In providing services to the homeless, clinicians
  reported numerous challenges
• Frustration in not being able to provide the high
  caliber of services they want to for the client
• Burn out from working with seriously ill and
  needy clients
• Frustration from noncompliance or when
  appointments are not kept
• Frustration by the lack of time case managers are
  allotted to spend with each client
• Prohibitively high case loads

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Challenges for Providers (continued)

• Pressed by time and, thus, must focus on crisis
  management as opposed to treating the root of the
  problem
• Need for more clinical support from supervisor to
  discuss difficulties with clients
• Lack of continuity of care and poor documentation
  to carry the client on to the next step

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inquire within
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Mindfulness Exercise
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Mindful Awareness

• Mindful Awareness is the moment-by-moment process
  of actively and openly observing ones physical,
  mental and emotional experiences.
• This approach has scientific support as a means
  to reduce stress, improve attention, boost the
  immune system, reduce emotional reactivity and
  promote a general sense of health and wellness.

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Today, be aware of how you are spending your
1,440 beautiful moments and spend them wisely.

• Buddha

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• Where do we go from here?

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Remember

• Everyone has a right to a place they can call
  home.