LOS ANGELES – The nation's largest homeless population lives here, generating a significant dose of a particularly thorny societal problem associated with homelessness: Where do you send a homeless person discharged from a hospital?
This week marks the second anniversary of a Los Angeles City ordinance that made it illegal to discharge a homeless patient to the street without consent and also prohibits other cities from "dumping" homeless patients here.
Los Angeles County's public safety net system has developed singular expertise in dealing with homeless patients. Social workers help coordinate discharge and obtain patient consent to document the assistance patients are offered to reach his or her appropriate destination.
Beginning in 2005, reports began surfacing that Los Angeles-area hospitals were discharging homeless patients back to the streets, instead of to the custody of a relative or shelter. Citing "the infamous practice known as homeless patient dumping," Los Angeles City Ordinance 179913 passed on May 16, 2008, making it a misdemeanor for any hospital facility to transport patients anywhere other than their residences without their informed consent. When the ordinance passed, City Attorney Rocky Delgadillo counted 55 reports of dumping over the previous 12 months.
The ordinance stated that placing discharged homeless patients on the streets was not only unsafe and a risk to patients' well-being and recovery, but a clear indication that institutions were placing financial performance above humanitarian concerns. The ordinance also noted that Delgadillo had been negotiating with certain hospitals for more than a year, encouraging the establishment of reasonable and uniform discharge protocols and best practices, yet patient dumping persisted.
The Los Angeles Homeless Services Authority estimated the city's homeless population at just shy of 43,000 last October. Other estimates range as high as 77,000.
About 17,000 homeless patients are treated each year, and 6,000 are admitted to hospitals in Los Angeles County, according to Jim Lott, chair of the Hospital Association of Southern California. Homeless patients typically are in the hospital four days longer than other patients, at an average daily cost of $1,241, which is usually absorbed by the hospital, Lott said.
"Although they came to us off the street, we can't put them on the street. Shouldn't that be someone else's social obligation?" Lott asked.
Recuperative Care Option
The concept of recuperative care came about as a means to discharge homeless patients to an address that was not a hospital or nursing home. The National Health Foundation in Los Angeles had been assessing recuperative care needs when the dumping ordinance passed, said NHF Chair and CEO J. Eugene Grigsby.
"We asked, 'Was there a genuine need for recuperative care countywide that hospitals would use and could the model be developed that would be self-sustaining and not rely upon grant-making or government funding?' The answer to both is yes," Grigsby said.
NHF estimated that close to 1,000 people per year in Los Angeles County might need such care.
In March 2008, the hospital association -- along with Los Angeles County, a private not-for-profit health agency called JWCH Institute, Kaiser Permanente, Neighborhood Legal Services and NHF -- started a two-year demonstration project -- the Los Angeles Recuperative Care Program -- to increase the number of homeless recuperative beds available to private hospitals in Los Angeles County.
Despite hurdles and roadblocks, the program added recuperative beds for private hospitals and a total of 4,100 days of recuperative care were provided. The program proved financially sustainable, according to the Hospital Association of Southern California. It ended in mid-March this year, but a "new, improved" model, the Orange County Recuperative Care Program, has taken its place. Launched on Jan. 4, the new program -- run by the hospital association, NHF and community leaders -- already cites a quicker referral process and shortened length of patient stay, both examples of having overcome "programmatic barriers."
Organizers say the new program is better because of the lessons learned from the demonstration project.
Although the new program's focus is Orange County, there’s still momentum to reconfigure a program for Los Angeles. The hospital association and NHF have identified several potential partners and plans are underway to incorporate many of the successful changes already working in Orange County in Los Angeles. In the meantime, JWCH has agreed to continue providing recuperative care services to private hospitals in Los Angles County.
The recuperative care program at JWCH Institute provides transitional housing, meals, case management and medical care to homeless people who are recovering from an acute illness or injury. JWCH operates 30 recuperative beds at Bell Shelter in Bell and 45 beds at Weingart Center downtown.
"It's difficult to balance constituents' needs, a societal problem we deal with every day," said Marcus Hong, director of recuperative care for JWCH.
Discharge by the Book
"A thoughtful discharge process" is standard procedure for Los Angeles County's Department of Health Services, said spokesperson Michael Wilson. DHS treats more than 300,000 emergency and trauma victims each year and operates four hospitals, two multiservice ambulatory care centers and six comprehensive health centers.
A 21-point DHS document of protocols and procedures states that all homeless patients and unstably-housed patients must receive a comprehensive discharge plan that begins at admission and involves appropriate levels of health care staff, community-based service providers and the patient, family or others.
Discharge to "nowhere" isn't an issue if patients have "somewhere" to go, and the county gets that.
"We feel we are approaching the problem of chronic homelessness in a very thoughtful and meaningful way by partnering services with housing to create more permanent supportive housing in L.A. County," said Libby Boyce, homeless services manager for Los Angeles County's Department of Health Services.
However, she added, "The reality is we are struggling and straining to serve folks that need care. We have folks who have to stay for a lot longer than acute care requires. Bed control and ER processes ultimately impact the entire system."
Boyce did note the success of the county's progressive Access to Housing and Health program, developed to provide permanent, affordable housing linked to case management services for homeless people who are frequent users of the DHS hospital system. The program was designed to help improve clients' access to medical care, mental health care, alcohol and substance abuse treatment, and other supportive services.
Originally a two-year project, the program has been expanded by two years with the contract ending Dec. 31 this year. "We have interest from the program's creator, Los Angeles County Supervisor Don Knabe, to re-fund AHH for additional time," Boyce said, adding that several details have yet to be worked out.
In a newsletter last year, Knabe said the program created permanent housing opportunities for dozens of homeless and saved $800,000 in medical and hospital costs in the past year.