By Lillian Dunn, RN, BSN and Yehudit Tawil, LCSW, MSW with Patricia A. Furci, RN, MA, Esq.
ED. NOTE: This is the second in an occasional series of articles about hospitals dealing with homeless patients. Patricia A. Furci authored the first article on the subject for RACmonitor on February 1, 2011.
While it is essential that all potential and actual homeless patients are detected very early during their hospital admission, the significant rise in the number of homeless and the complexity of treating these patients, both medically and socially, presents multiple challenges to all the healthcare professionals on the team providing care and planning for discharge.
To avert a poor outcome in the treatment and discharge planning process, a comprehensive assessment of demographic, clinical and psychosocial information should be performed as quickly as possible. The development of specific screening criteria identifying incidence of high risk is critical, as it can be used as a guideline for case managers and social workers to recognize the possible homeless patients who have the greatest need for timely discharge planning intervention and post-hospital discharge needs.
In addition, taking things one step at a time as outlined in the article may provide for better treatment and discharge planning for this challenging population group.
High-Risk Screening Criteria
When developing or using high-risk screening criteria for early identification of homeless patients, it is important to include and look for the following:
- The absence of an address or an incorrect address on a demographic face sheet or intake sheet;
- The absence of an active phone number or an incorrect phone number on a demographic face sheet or intake sheet;
- A patient's claim that he or she is living in the street, in a shelter or in a car;
- Few or no identified social supports or support groups;
- The absence of a payer source;
- A patient being unemployed or underemployed; and
- A patient's record indicating multiple admissions to hospitals.
If the patient's assessment triggers these high-risk screening criteria, then immediate proactive discharge planning needs to be initiated. Hospitals need to be creative and innovative in their approach to a solution, as each homeless patient and his or her situation is unique and must be handled on a case-by-case basis.
Can Relatives Be Located?
The process of finding relatives of a homeless patient (or any patient) always can pose a challenge to the healthcare professional. Of course, the best first course of action is to speak directly to the patient. It also can be helpful to have a case manager and a social worker both interview the patient at different times, as the patient often will provide different information to each healthcare worker. Sometimes the patient will provide names and numbers of friends or neighbors who may be able to provide additional vital information. This discussion with the patient must occur before you proceed to a search for family members.
Secondly, the patient needs to be agreeable to the discussion and made to understand that the goal is to assist with his or her post-discharge needs while ensuring a safe discharge when medically stable.
The next step is to have in-house legal counsel get involved by becoming familiar with the circumstances surrounding the patient and conducting a thorough family search.
Once legal counsel works collaboratively with the case management department, you will see that outcomes will prove to be successful. An open and honest approach must be taken in communicating with relatives who may be estranged. Introduce yourself and communicate the reason for your call.
Allow the estranged family member to verbalize any feelings of anger, frustration or rejection towards the patient and situation. Respect their feelings, but emphasize your objective to assist the patient and ensure a safe and appropriate discharge plan. The outcome of these talks may not always be favorable, but occasionally the estranged relative will have a change of heart about their relationship with the patient and make attempts to reach out and assist.
What about Guardianship?
Guardianship is not always the right solution. The patient's specific circumstances must be assessed first. There are times when an individual needs to make informed decisions for life-altering choices involving matters like medical interventions, participation in medical treatment and discharge plans, but often the patient requires assistance with these decisions.
There are legal documents that can be utilized instead of pursuing guardianship. Determining early on in an admission if the patient has an advance directive/healthcare proxy or power of attorney (POA) is an integral part of the process, beginning in admitting, then in the nursing unit and again on discharge planning assessment. If the patient does possess one of the three, a copy should be requested from the patient and/or a family representative and placed in the medical record. If the patient comes from a nursing home, a copy of these documents should be found within the paperwork from the nursing home. Otherwise, the hospital should request a copy.
Although, the decision to have an advance directive is voluntary, a social worker can educate the patient and/or family representatives about the importance and benefits of having certain legal documents, plus how to go about getting them. It is also crucial for the social worker to establish contacts upon admission and involve in-house legal counsel as necessary if confirmation that no family exists is attained.
When there are no legal documents, no advance directive, no healthcare proxy and no family - and the patient appears to be incapable of making responsible medical decisions - the case manager should speak with the attending physician as soon as possible and obtain an order for a psychiatric evaluation to determine capacity.
Guardianship only then should be pursued if the psychiatrist deems the patient to be lacking the capacity to make decisions and the attending physician is in agreement. Guardianship is utilized as a last resort since it is an extreme measure that greatly limits a patient's independence and can be a costly legal process for hospitals.
Discharging the Homeless: How to Help a Patient Become "Shelter Ready"
When you are working with patients who may need to enter a shelter upon discharge, you first need to determine whether your homeless patient will meet the requirements of a shelter. Most shelters allow fully able persons only, or those who can navigate stairs, communicate verbally and prove to be able to manage their lives while remaining ambulatory.
Shelters typically do not allow canes or walkers, as both of these could be considered weapons. Shelters do not allow injectable medications for the same reason, therefore your insulin-dependent patient may not be a candidate. It is also important to determine if your patient can manage his or her daily life and find food during the day since many shelters are only open nights.
Secondly, it is imperative for the case manager and the social worker to consider additional criteria when assessing if your patient is ready for a shelter. If there is a wound, make sure the patient is capable of performing their own wound care with a level of competency, since there will not be any medical or visiting nurse service at the shelters. It also is a good idea to have the nurse educators play a role in making patients shelter ready. In addition, be sure to have your physical therapy staff work with these patients as aggressively as possible, especially on ambulation and negotiating stairs, as many shelters are located in building basements and require guests to climb into a top bunk. Working with the physical therapists twice a day should be standard for this kind of patient.
It also is very important to provide the patient with addresses and directions to the local soup kitchen as well as to the local board of social services, where they might find that they are eligible for a stipend of some kind.
Moreover, become familiar with the different shelters in your area. Shelters often have different requirements and resources, and there might be one further away that can host your patient for a month without putting them on the street during the day (but you might have to put the patient on a long cab ride to get there).
In addition, do not overlook the chance that a patient recently may have been a resident of another state or county where a bottom bunk might be available. Work with the physicians on practical medications and treatments. There may be an alternative to the injectable medication they ideally would prescribe that works just as effectively but may not be as popular. The key is to involve the whole medical team in the discharge plan to overcome obstacles in having your patient become shelter ready as soon as possible.
Working with the homeless patient in a hospital setting is a challenge not only for the case managers and social workers, but for the entire healthcare team. Be sure to communicate with team members frequently and determine the safest and most reliable discharge plan possible.
And take it one step at a time.
About the Authors
Patricia Furci, RN, MA, Esq., is currently part-time, in-house Counsel at several hospitals, providing legal services specially addressing inpatient issues, Case Management functions and Guardianship services.
Lillian Dunn, RN, BSN, is Director of Continuing Care at Palisades Medical Center located in North Bergen, New Jersey. In her position, Ms. Dunn is responsible for overseeing case management, utilization management, and discharge planning for the hospital.
Yehudit Tawil, LCSW, MSW, has been employed in the Clinical Case Management Department of Robert Wood Johnson since May of 2001. At Robert Wood Johnson she has worked as the social worker on the Heart Transplant Team, for general medical floors and worked for several years specializing in complex discharges.
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