San Francisco Medical Respite: Defining a Successful Discharge

1
San Francisco Medical RespiteDefining a
Successful Discharge

• Michelle Nance, RN, NP - Midlevel provider
• Michelle Schneidermann, MD - Medical Director
• Shannon Smith, RN,MS,CNL - Intake Coordinator
• Alice Y. Wong, RN,CNS - Nurse Manager

2
Objectives

• Briefly describe the San Francisco Medical
  Respite Program
• Describe measures of success respite programs can
  use when evaluating discharges
• Describe the internal and external philosophies
  that influence discharge from medical respite
• Learn to identify and incorporate hospital and
  community needs into discharge planning

3
(No Transcript)
4
Mission Statement

• The mission of the Medical Respite Program is to
  provide recuperative care, temporary shelter, and
  coordination of services for medically and
  psychiatrically complex, homeless adults in San
  Francisco.

5
Values

• We believe that
• Every person has the right to housing, health
  care, and food security.
• All people have the right to self-determination.
• Every person is valued and entitled to dignity
  and respect.
• Homelessness is the result of a complex set of
  circumstances and necessitates a multifaceted
  approach toward resolution.
• A dedicated team can have a positive impact on
  the life of individuals and the community.

6
Vision

• Our vision is to
• Encourage healing and stabilization by providing
  respite from homelessness
• Provide individualized assessment of client needs
  and a comprehensive plan of care
• Advocate a harm reduction model to decrease the
  negative impact of unsafe behaviors
• Provide compassionate, nonjudgmental,
  interdisciplinary, and state-of-the-art care
• Collaborate with local entities to coordinate
  provision of care, options for housing, and
  initiation of entitlement process and
• Forge relationships with local, regional and
  national networks of those who serve homeless
  persons.

7
The Vulnerable Medically Complex Homeless in SF
8
SF Homeless DemographicsSan Francisco Homeless
Count 2007

• Done by SF Human Services Agency, March 2007
• African American/Black 47.6
• Caucasian 43.4
• Male 80.2
• Female 19.4
• Transgender 0.3
• Sheltered Homeless
• Transitional Housing and Treatment Centers
• Resource Centers and Stabilization
• Jail
• Hospital
• Unsheltered count
• Total Count n6,377

9
Health and Homelessness

• The average life expectancy of a homeless person
  is 42-52 yrs (average in US is 80 yrs)
• Homelessness magnifies poor health
• Exposes people to communicable illness and trauma
• Complicates management of chronic illness
• Makes health care harder to access
• Homeless patients are more likely to be seen in
  ED and admitted and have longer LOS than other
  patients
• Salit, S. et al (1998)

10
The Hospitalized Homeless

• Treatment plans that make sense for housed
  patients dont work for homeless patients
• No bed for bed rest
• Difficult to keep wounds clean
• Adherence to meds and appointments suffers
• Impossible to follow diet and exercise
  recommendations
• Often have no support system to help with
  treatment plan

11
Hospitalized Homeless The San Francisco
Experience

• Around 20 - 30 of patients admitted to San
  Francisco General Hospital (SFGH) are homeless
• Most of those patients are chronically homeless
• Safe and effective discharge plans are difficult
  to construct

12
What Respite Offers

• Successful resolution of acute conditions and
  stabilization of chronic conditions
• Linkages to additional services
• Development of plans focused on positive
  long-term changes
• Recuperation from not only physical illness, but
  also the emotional distress and isolation that
  accompany homelessness

13
Demographics of SF Medical Respite Program

• Ethnicity (and Gender) Reflect homeless
  population of San Francisco
• Gender 80 male/20 female

14
San Francisco Hospitals

• The Medical Respite accepts clients from 10 area
  hospitals.
• San Francisco General Hospital and Trauma Center
• 300 bed acute care public hospital including
  only Level 1 Trauma Center in San Francisco area.
  
• Nine other community hospitals
• Total 2,200 Hospital Beds

15
Referring Hospitals

• Note Other clients came from outpatient surgery
  and DPH case management programs

16
(No Transcript)
17
Discharge Venues in San Francisco

• Permanent Housing
• Direct Access to Housing (DAH)
• Supported (may include SW, CM, RN)
• Single Room Occupancies (SRO)
• Non-supported
• Supported (may include SW, CM, RN)
• Apartment/ House

18
Discharge Venues

• Shelter System
• GA Shelter Bed 30-90 days
• A Womans Place shelter up to 6 months
• City shelter Case management up to 6 months
• City shelter No case management 1 week

19
Discharge Venues

• Higher Level of Care
• Board and Care
• Long Term Care Facility
• Emergency Department/ Inpatient Services
• Residential Treatment
• Hospice

20
Discharge in the Literature

• Zerger, S (2006) Discharge standard of practice
  is that a clients primary admitting diagnosis
  has been stabilized prior to discharge
• RCPN practice models state a safe discharge from
  respite care entails follow-up services

21
Program Measures of Success Short Term

• Completion of treatment plan, including
  demonstrated independence with self-care and
  medication management
• Improved living situation after discharge from
  Respite
• Engagement with primary care and specialty care
• Linkages to social services, benefits
• Referrals to mental health and substance abuse
  services

22
Medical Treatment Plan Completion
23
Treatment Plan
24
Treatment Plan Completed!
25
Length of Stay by Days and Disposition

26
Discharge Disposition
27
Linkages Made at Respite Medical Services
28
Linkages Made at Respite Social Services
29
Internal and External Philosophies
30
External Philosophies Hospital

• Enormous amounts of energy are spent
  re-stabilizing many of our homeless clients.
  Rather than successful long-term management we
  frequently are only treating acute exacerbations
  of the chronic conditions. Respite has been able
  to provide stability and management to many of
  our clients.
• - SFGH Attending Physician

31
External Philosophies Hospital

• Wed love to see people get into housing,
  especially the frequent flyers. However, we want
  to be able to refer more people and there is
  often a wait for a bed. So we cant refer to you
  Respite if you do not discharge clients to
  shelter, as there are not enough beds.
• The perfect discharge would have them go into
  some type of housing, an SRO. Transition back
  into the community in some sort of living
  situation, rather than back into the streets.
  But I know we dont live in a perfect world.
• -SFGH Discharge Social Workers

32
External Philosophies Community

• Our homeless clients, in general, use our
  ambulances and EDs much more frequently than the
  typical housed client. In addition to
  overburdening the emergency medical service, this
  care does not address their long-term needs. They
  need access to regular medical care and
  medications, stable housing, psychiatric and
  substance abuse services, case managementThe
  ideal scenario would be to establish all of this
  prior to their discharge. To give them a solid
  network of support.
• -San Francisco Paramedic Captain

33
External Philosophies Community

• We have few expectations of what you do for
  clients because we assume they dont have
  anything. What we like about Respite is at least
  their medical linkage is done.
• -SF HOT (Homeless Outreach Team) Case Manager

34
Referral Difficulty

• Inpatient teams often express the enormous
  pressure they are under to discharge their
  clients.
• We need to discharge today

35
Referral Difficulties

• Inappropriate referrals lead to difficult
  discharges
• Need higher level of care than indicated
• Incontinence, dementia, not competent, not able
  to care for ADLs
• No acute medical need but a number of
  co-morbidities needing longer-term management
• What is the end point for discharge?

36
Internal Philosophies

• Multidisciplinary staff
• Nursing, midlevel providers, MD
• Administration
• Social workers
• Paraprofessional staff (medical assistants,
  health workers)
• How do we define a good discharge?
• How do our internal philosophies match our stated
  mission?

37
What Is a Good Discharge?

• Our biggest discharge issue is the lack of
  available, affordable quality supportive
  housing.
• John Wiskind, LCSW
• In reviewing success, we look at whether
  people are still housed a year later.
• Mark Hamilton, MSW
• Individual housing is the gold standard
• Cindy Lee, RN

38
What Is a Good Discharge?

• Completing the acute medical need, but thats
  balanced with the need to more permanently
  offload burden from the emergency services and
  hospitals.
• Michelle Nance, NP
• Completion of acute medical condition without
  being readmitted into the hospital.
• Shannon Smith, RN

39
What Is a Good Discharge?

• A bad discharge is when we have to call the
  police. A good discharge is when we have done all
  we can do for someone.
• Jeanne Andaya, MEA
• The acute medical need is done.
• Tae-Wol Stanley, NP, Program Director
• The medical need is done, they are started with
  linkages, and discharged with reliable follow up
  
• Alice Wong, RN, Nurse Manager

40
What Is a Good Discharge?

• A good discharge means that while at respite, a
  patient has completed his/her treatment plan,
  engaged in primary care, learned self-care and
  medication management skills, and has begun the
  process of transitioning into permanent housing. 
  There are some patients too vulnerable to be
  discharged from respite back to the shelter
  system and a successful discharge for those
  patients would include a move from respite
  directly into permanent housing.  While in my
  fantasy world, all patients would discharge into
  permanent housing, the real world of limited
  resources forces us to triage.
• -Michelle Schneidermann, Medical Director

41
What Is a Good Discharge?

• At minimum a resolution of a medical issue in
  an environment that is less costly and more
  normalized than the hospital. Even a short time
  (10-15 days) of recuperation that can be done at
  Respite rather than inpatient is cost saving. A
  good discharge is when a client leaves better
  equipped to find a next phase of a residential
  setting. Id like to see direct uninterrupted
  access to a bed in the system, whether shelter,
  treatment, stabilization or permanent housing.
• - Mark Trotz, Director, Dept of Housing and
  Urban Health

42
Internal Philosophies

• Staff have different philosophies shaping their
  discharge decisions
• Can lead to confusion and conflict for both staff
  and clients
• Of note no clients were asked for a definition
  of a successful discharge for this presentation

43
Who Gets Prioritized for Housing?

• Older
• In our population, 50 years old is old
• Medically frail
• COPD requiring oxygen
• Hemodialysis
• Terminal or severe cancer diagnosis
• Amputation, paralysis
• Tired
• Done with the player lifestyle
• Willing to engage
• Most unstable/disruptive to system
• Heavy Emergency Services use

44
Pre-Hospital Living Situation
45
Living Situation at Respite Discharge
46
Living Situation

• 51 of clients had a change in living situation
  for the better
• 44 of clients had no change in living situation

47
Is Individual Housing the Gold Standard of a
Discharge?

• What a lot of clients need is a mom and thats
  what they get at Respite nagging, reminders,
  family and friends, increased social
  interactions, meals. They lose this in housing.
• Cindy Lee, RN
• We tend to think of housing as the gold
  standard, but for many clients having an
  individual room doesnt work they decompensate
  in that situation.
• John Wiskind, LCSW

48
Is Housing the Gold Standard?

• Supportive Housing (SH) programs become less
  willing to take our clients because the clients
  are too sick/disorganized
• SH asked to be hospice lite staff gets
  overburdened and burned out
• Should we prioritize less sick clients for SH
  instead of the most fragile so theres more
  success?
• Are there other options?

49
Next Steps?

• Creating more communal living situations
• Smaller group homes with support services
• Encouraging community in SROs
• Foster creation of Medical Rest Beds in Shelters
• For clients who are awaiting housing
• Communal living
• Medical/social support
• Free up Respite beds for acute needs
• Get more data
• Who do we really house?
• Outcomes for housed
• Objective 911 calls, hospital readmits,
  evictions
• Subjective clients perceived mood, substance use

50
Next Steps?

• Re-examine our internal philosophies on discharge
• Create more objective measures for who we hold
  for housing
• Assessment tool
• transplant waitlist
• Formalize team discussions of referrals
• e.g., a tumor board for housing
• Respite Alumni Network

51
Incorporating These Philosophies into Discharge
Planning

• Identifying when housing IS the gold standard and
  appropriate
• Ex Client is medically complex and ready to
  engage
• Triaging and creating individualized discharge
  plans based on medical and psycho-social need and
  willingness to engage
• Education and understanding that sometimes a
  successful discharge does not include a direct,
  uninterrupted discharge to housing

52
Case Studies
53
Mr. B

• 66 year-old man with a long history of asthma,
  COPD, asbestos exposure, tobacco and alcohol
  abuse, and depression, who was admitted to the
  hospital for pneumonia.
• X-ray and CT scan of the chest showed large
  masses in his lungs
• Confirmed to be extensive small cell lung cancer
• Started on chemotherapy and transferred to
  Medical Respite 6 days later

54
Mr. B At Respite

• Admitted on January 31, 2008 for assistance with
  follow-up chemotherapy treatment and appointments
• Stayed at Respite for 78 days until discharge
  into Supportive Housing
• Stopped drinking
• Reconnected with his daughters in OK

55
Mr. B After Respite

• Came back to visit and showed us pictures of his
  granddaughters after a visit to see his family in
  OK
• Had last day of chemo and decided to celebrate
• Relapsed for 9 days when his case manager finally
  found him
• Was admitted to a detox facility
• Returned to supportive housing
• January 2009 entered hospice care
• March 2009 Mr. B died in hospice

56
Mr. M

• 33 year-old man with a history of poorly
  controlled diabetes, polysubstance abuse,
  depression, post-traumatic stress disorder,
  schizoid personality disorder, admitted to the
  hospital for DKA.
• Immigrant from DRC
• History of being boy soldier, imprisonment, and
  torture
• Poor adherence to insulin regimen
• Admitted to Respite for stabilization of blood
  glucose levels while awaiting follow-up
  appointment with primary care provider

57
Mr. M At Respite

• Challenges
• Cultural Issues
• Complex psychiatric history
• Brittle diabetic
• Behavior at Respite
• Compliant with medication regimen and medical
  needs
• Patient split between professional and
  paraprofessional staff
• Threatened to kill a Respite Worker

58
What Would You Do?
59
What We Did

• No tolerance policy for violence
• Partnered with patients pre-existing case
  manager
• Behavioral contract until case manager could find
  alternative place
• Capitalized on respect for clinical staff to
  continue managing his medical need
• Case manager was able to secure a 28-day
  stabilization room 24 hours later

60
Mr. C

• 52 year old man with history of CHF, CAD, CVA
  with L hemiparesis and slurred speech w/c bound
  hidradentitis suppurativa microcytic anemia
  HTN Hep B Hep C. 35 pack-year tobacco history
  denies ETOH or SA
• Left buttock wound with fistula
• Staying in shelters and had been unable to do
  wound care on own so presented to the Wound Care
  Clinic.
• Was hospitalized for a left buttock abscess and
  fistula
• Referred to Respite for ongoing wound care of the
  perirectal area and bilateral buttock and to f/u
  with PCP for his microcytic anemia.
• Also needed IHSS worker

61
Mr. C At Respite

• Respite cannot offer a hospital bed
• Was not independent with bathing required
  two-person assist with bathing and wound care
• Not always compliant with wound care and hygiene
  recommendations
• Lost Section 8 housing and wait list was long for
  ADA room
• IHSS worker would be helpful, but needed housing
  first
• Wound began to worsen
• Was found with frank blood soaked through clothes
  and sheets on bed from the wounds

62
What Would You Do?
63
At Respite Mr. C

• Engaged with Mr. Cs primary care provider
• Wound was to extent it needed surgical repair
• Even if Mr. C went to housing with IHSS, an IHSS
  worker could not offer the kind of care the wound
  needed
• Issues
• To high level of care for Respite
• With the PCP we decided to discharge
• pts choice - shelter or hospital for FTT
• Agreed to admit to SFGH for FTT
• Respite Case Manager recently saw him at SFGH
  walking in the halls with a walker!

64
Mr. A

• 62 year old male s/p R hip fracture, hx of ETOH
• Admitted first to Respite and went AWOL the same
  day
• After 48 hours a hospital search found he had
  fallen while acutely intoxicated and refractured
  his hip
• Readmitted to Respite 1 week later

65
Mr. A At Respite

• Engaged with FSA Case Manager
• Decreased ETOH intake
• Gained weight
• Expressed desire for treatment program
• Respite challenge 290 status (sex offender)

66
Mr. A At Respite

• Realities of 290 status in San Francisco
• No inpatient treatment program in SF takes 290
  status
• Shelters discharge someone with 290 status
• No inpatient treatment program in Alameda County
  will take 290 status, either

67
What Would You Do?
68
Mr. A

• Medical Treatment Plan completed
• Engaged with primary care provider who he sees
  when he doses
• Went to stabilization room through FSA case
  manager
• Detox and ETOH treatment plan left to primary
  care provider

69
Ms. L

• 84 year old female with history of HTN, Afib,
  anemia, and CHF
• This was her only hospital admission on record at
  SFGH
• Admitted to Respite to finish antibiotics for BLE
  cellulitis
• No family involvement. Her only child and only
  sister have both died.

70
Ms. L At Respite

• Finished antibiotics
• Received wound care
• Engaged in primary care through Bridge Clinic
• Through ongoing primary care she became more
  medically complex and unable to self-manage her
  medications
• Accepted into supported senior housing in
  brand-new building
• Ms. L refused this housing stating, its too
  new.
• Found competent and not conservable

71
What Would You Do?
72
Ms. L

• Had 122-day length of stay
• Bridged primary care to Curry Senior Center that
  provides case management to low income seniors
• Discharged to shelter with case management
  through Curry Senior Center
• Respite received sad news Ms. L died at St.
  Francis Hospital on May 1, 2009

73
So What Is the Definition of a Successful
Discharge?

• No single definition of a good discharge
• We have identified two different conceptions of a
  good discharge
• Client discharges to a specific place
• Client has received services and links to
  services during stay
• In your community you have to balance your
  external and internal philosophies

74
Thank YouQuestions?