San Francisco Medical Respite: Defining a Successful Discharge

1. San Francisco Medical Respite:Defining 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

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: n=6,377

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 don’t 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

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 Woman’s 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 client’s 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 “We’d 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 can’t 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 don’t 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 management…The 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 don’t 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 that’s 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. I’d 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 that’s 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 doesn’t 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 there’s 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: client’s 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