Updated on: June 22, 2012

Breaking the Readmission Cycle of the Homeless: One at a Time

Original story posted on: July 19, 2011

pfurci100EDITOR'S NOTE: Patricia Furci continues reporting on the plight of the homeless seeking medical attention in local hospitals. Furci reminds providers that to have a RAC-safe discharge strategy.


Recently I was asked to see "Joe," a 76-year-old homeless patient, for a possible guardianship when I discovered that he had been admitted to the hospital as an inpatient more than 11 times in the last five months.

Not only was this a guardianship issue, but also one of breaking his cycle of revolving-door readmissions.


I started by reviewing Joe's prior admissions, comparing those with his current admission. There was no discernable correlation. His history indicated that he came in for his longstanding cardiac problem when he had nowhere to go. He usually slept in cars that he would find left unlocked. If there were no cars available, Joe would come to the emergency department, where he knew he would get admitted for his cardiac problem.


After consulting with case management staff, physicians, a temporary guardian, a court-appointed attorney and a judge, we were able to put together a plan for Joe.  We decided to assist him in becoming Medicaid-eligible even though we knew it would extend his hospital stay.


After a few short weeks, Joe became Medicaid-eligible. The case management staff quickly found a bed in a nearby facility and Joe left the hospital to seek a new home and start a new life. In his follow-up hearing with the court, sporting a new haircut and clothes, Joe told the judge that it was good to have people care for him, and that it wasn't that bad in the long-term care facility after all.


The judge dismissed the case and wished Joe much luck in his new life.


Getting everyone involved in the overall goal for many such cases - halting the readmission cycle - is imperative. This includes the court in question. The temporary guardian and court-appointed attorney need to be focused on assisting the hospital in getting the patient benefits so he can attain proper placement.


Although it took a few short weeks to get Medicaid benefits for Joe, it was worth the wait.  The revolving door of readmissions for Joe has ceased and he finally is getting the quality care he deserves.


I know we will not see Joe again soon, but there are others still caught in the revolving door.  We just need to catch them, even if it is one at a time.


About the Author


Patricia Furci is currently part-time, In-house Counsel at several hospitals, providing legal services specially addressing inpatient issues, case management functions and guardianship services.


Contact the Author




To comment on this article please go to editor@racmonitor.com


Prioritization an Essential Component of Providing Healthcare for the Homeless

This email address is being protected from spambots. You need JavaScript enabled to view it.