On a sweltering Wednesday afternoon last month, a tall, mild-mannered homeless man was walking up State Street when he became dizzy and short of breath. He sat down on a bench in front of Chipolte Mexican Grill and within minutes became unconscious. Forty-one-year-old William Richardson did not know he was a diabetic or that his blood sugar was soaring above 760. (Normal is 120 and below.) His body was shifting into the deadly state of ketoacidosis.

Coincidentally, Richardson’s mother was walking up State Street too, and saw her son just before he collapsed. She informed a Paseo Nuevo security guard, who called paramedics. Richardson was taken by ambulance to Cottage Hospital’s Emergency Room and admitted to the Intensive Care Unit (ICU). After two days of medical intervention, his condition stabilized. Nurses taught him how to inject himself with insulin–something he would need to do four times a day from now on. A little later, doctors deemed him ready for discharge. And that’s when a whole new set of problems arose: Richardson had nowhere to go.

Being discharged from the hospital is ordinarily a relief for patients, but for the majority of Santa Barbara’s homeless, it’s when life gets even more complicated. There are only two reliable facilities to which homeless hospital and Emergency Department patients can be transferred: WillBridge, a small residence for the homeless mentally ill, and Casa Esperanza homeless Shelter.

Skilled nursing facilities would be appropriate for some homeless patients, but as they require patients be covered by Medi-Cal insurance and have a physician who will oversee their care, they’re rarely a viable option. And because WillBridge is small and has no nursing staff, the majority of homeless patients who don’t want to return to the streets upon discharge are usually sent, via taxi, to Casa Esperanza.

Since the late 1970s, when it first became common to see people sleeping on park benches and in doorways in the nation’s urban centers, hospital discharge planners, shelter operators, and social service providers have wrestled with how to care for homeless patients who are no longer sick enough for hospital care, but too sick to live on the streets.

Compounding the problem is that hospital stays have shortened due to managed care, and patients are often sicker when discharged. In 2006, the issue became national news when a video camera outside a Los Angeles homeless shelter captured an elderly patient in a hospital gown looking confused and lost as she stepped out of a taxi following her discharge from Kaiser Permanente. After investigating over 40 separate allegations of “patient dumping” by 10 different L.A. hospitals, only Kaiser was charged with criminal false imprisonment and dependent-care-endangerment.

As part of an Online Community Building and Health Fellowship offered by the USC Annenberg School for Communication & Journalism, The Santa Barbara Homeless Blog has been examining what happens to homeless patients after they are discharged from hospitals in southern Santa Barbara County. I’ve tracked four homeless people who have received care at Cottage Hospital recently. The three men and one woman, including Richardson, have unique stories and struggles, but each one is homeless, broke or close to it, and without family nearby who can take them in. Their stories illustrate the most common outcomes for homeless patients here and suggests ways in which the discharge system could be improved.

I also visited two other California cities, San Jose and Los Angeles, to learn how they are managing the needs of recuperating homeless patients in their areas.
There hasn’t been any patient dumping in Santa Barbara, as far as I can tell. Homeless patients are never discharged without some planning for their aftercare; everyone is offered, at minimum, a bed at Casa Esperanza, where they will be given one week of unlimited bed rest and access to nursing care. Sometimes, a bed at the smaller, quieter WillBridge is available, where there is case management but no nursing staff. Cottage Hospital’s discharge planners and the staff of Casa Esperanza and WillBridge are all doing their best within this system.

Unfortunately, the system is uncoordinated and under-funded. Todd Cook. director of Quality Control at Cottage  Health System, said the hospital is almost always able to provide a safe place to discharge people. “We wouldn’t let them just go without having a safe handoff and feeling comfortable that he next level of care that they’re going to get will be sufficient to meet the needs of whatever conditions they’re working through,” said Cook.

Even so, it’s not uncommon for Casa’s  staff to send a discharged patient back to Cottage because he  or she is too weak to perform basic daily functions, like getting himself to the bathroom. And it is also not uncommon for patients to arrive at Casa without their prescribed medicines or with the wrong medicine. The inefficiencies inherent in this system, including readmissions, are likely costing Cottage Hospital and the community more than it would cost to run a 24-hour medical respite center for recuperating homeless people. Research has established the cost savings of these programs, which are sprouting up throughout the country.

But I am getting ahead of myself.

In a 7-part series that will run on The Independent webpage (www.independent.com) and on the Santa Barbara Homeless Blog (www.homelessinsb.org) over the next few weeks, I will tell you about:

–Fifty-seven-year-old Mary Manning (a pseudonym, at her request), a Santa Barbara native who was living in a rented room on the Westside when she began chemotherapy for a recurrence of breast cancer. Still recovering from a mastectomy, she reacted badly to the drug and became weak, disoriented and unable to care for herself. One afternoon before Labor Day, Manning found her way to the Emergency Room, where doctors admitted her for dehydration and anemia. After 10 days, she was discharged to Casa Esperanza, but ended up back at Cottage for another week before being discharged to a nursing facility;she ultimately landed at WillBridge.

–William Shea, 47, had been camping on the grounds of Christ the King Church in Goleta for over a year. In early September, Shea woke up so winded that he could barely walk. A parishioner drove him to Goleta Valley Cottage Hospital’s Emergency Room, where he was diagnosed with congestive heart failure. After two days of inpatient care, he was discharged to WillBridge. In the next month, Shea regained some strength, and was receiving case management. But with funding for WillBridge’s respite beds depleted, Shea was informed he would soon have to move to Casa Esperanza. On Wednesday of last week, he disappeared from the house and hasn’t been seen since.

–Michael Stowell, a former computer programmer who was laid off in 2007 and became homeless because of debts he incurred while recuperating from a hip broken in a bicycle accident. A year following his hip repair surgery, his hip began hurting. An X-ray revealed blood supply to the ball of his left hip joint had been cut off, leading to a condition called Osteonecrosis, or bone death. Stowell would need a hip replacement. But in the interim, he developed a hernia, which took priority over the hip replacement. His hernia was repaired in late August under the Medically Indigent Adult (MIA) program here, and afterwards, Stowell was discharged to Casa Esperanza. His recuperation was uncomplicated, but he was informed after a week that he would no longer be able to rest in bed during the day. Given how painful walking had become, Stowell found this policy unfair, and after a few more weeks, left Casa to stay at the Rescue Mission, where he is sleeping on the floor of the Mission’s chapel at night, and spending his days at the library. His hip surgery has yet to be scheduled.

Between January and September, Cottage’s Emergency Department discharged 267 homeless patients to the street, almost always at their request. The hospital doesn’t keep data on acute care discharges of homeless people, however, Casa Esperanza received 306 Cottage patients between January and September; WillBridge received 15. The hospital gives money to both programs to accept their homeless patients. Casa received its largest grant ever from the hospital this year–$125.000. The shelter’s executive director, Mike Foley, said they bill the hospital $39 per medical bed for each night a patient spends there, up to $125,000. After that, the beds will be provided for free.
Lynnelle Williams, Willbridge’s executive director, said her program received $20,000 from Cottage Hospital for its respite bed nights in 2011. But as of October 14th, those funds were depleted. There will be no more patients referred to WillBridge until January 1st, Williams said.

A 1998 New England Journal of Medicine study found homeless patients stay an average of four additional days in hospitals compared to “housed” patients suffering the same conditions. Cottage spokesperson Janet O’Neill said it costs $1,200 to simply keep a patient overnight there, not including medical care. As few homeless patients have insurance, this cost is almost always borne by the hospital.

Though Richardson’s discharge from Cottage was discussed and planned, it was hardly smooth. WillBridge had a bed for him. His mother accompanied him there with his medication. But when intake manager Nick Ferrara completed the paperwork, he decided Richardson’s condition, with the requirements of a special diet and inexperience with giving himself shots, was too fragile. So Ferrara let Richardson stay the night, but took him back to Cottage in the morning. At the ER, nurses gave Richardson his shots and more training in insulin injections. He was sent to Casa Esperanza around 5 pm. At Casa, Richardson objected to having a top bunk, and began feeling dizzy again. He went back to the ER. Once again, Richardson, who has a learning disability, was given his shots, more training, and sent back to Casa where staff let him sleep downstairs in the lobby. The next day, when he went to give himself his injection, he discovered the hospital had given him insulin pre-loaded insulin pens, not the vials and syringes he was trained to use. He’d never seen the pens before, plus he was feeling dizzy again. The shelter nurse sent him back to the ER in an ambulance, where nurses showed him how to use the pens.
Gradually Richardson is adjusting to having diabetes and to living in the chaotic surroundings of Casa. He has been to the ER two more times since that first bumpy weekend and describes the whole experience as scary.

“At first I didn’t want to come [here] because I knew there were a lot of people and a lot of drama,” he said. He was happier when he found out he was going to WillBridge. “I guess it was a misunderstanding,” he said.

By Isabelle T. Walker

This article was conceived and produced as a project for the Online Community Building and Health Fellowship,  which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.
 

Photo by Paull Wellman of  William Armstrong, a.k.a. Kickstand, who was recently released from Cottage after a lengthy stay in Cottage Hospital. Armstrong, recovering from pneumonia, is staying at Casa Esperanza on a medical bed. 

Über prosperous Silicon Valley isn’t a place one expects to find thousands of homeless people. But a 2006 Housing and Urban Development (HUD) count found over 7,600 men, women and children without a home in Santa Clara County, which includes not just Silicon Valley but Palo Alto and San Jose.
Unnerved by the count, the Santa Clara County Board of Supervisors commissioned a Blue Ribbon panel on Ending Homelessness and Solving the Affordable Housing Crisis. One of the panel’s recommendations was that a facility for homeless people just released from the hospital be started, so there would be a place for them to recuperate fully. Surprisingly, in 2008, seven private and public hospitals from up and down the county, including Stanford University Hospital, began collaborating on The Santa Clara County Medical Respite Center.
In its first two years, the center spared participating hospitals 783 bed days. As the average cost of a bed day in that area is between $3,000 and $1,000, that’s works out to be roughly a million dollars in savings in the program’s first two years.
The respite center is situated in wing of a sprawling San Jose homeless shelter called EHC Life Builders. Though close to the big shelter, the center is distinctly separated, along a long wide corridor that’s breezy and clean with linoleum floors and sofas for socializing and reading. Along the corridor are seven bedrooms. Six have two beds, one has three. Janet Kohl, RN, is the nurse coordinator who ensures residents are following their plan of care and completing paperwork for Social Security Disability (SSI) and Medi-Cal. Those things are what ultimately get the residents into housing. Also on staff is a fulltime social worker, a part-time internist, partime psychologist and partime psychiatrist.
The program is basically “Pay to Play.”  The seven original hospitals, and two others that have since joined the collaboration, give $25,000 a year to fund operation of the facility. The county hospital, Santa Clara Valley Medical Center, pays for the five-person staff through its federal Healthcare for the Homeless Program. For their money, each of the nine hospitals gets to refer homeless patients to the center—as long as they’re able to do three things: walk to the bathroom, walk to the cafeteria for meals, and take their own medication. The hospitals end up avoiding expensive, unnecessary bed-days in which homeless people linger around because they have no place to go. They also get to avoid readmissions for conditions that didn’t heal, which in some cases could result in a fine from Medicare.
Kohl said the program is a win-win for everyone. However, not every patient referred can get in, according to Kohl. With only 15 beds, and the average length of stay 66 days, sometimes there isn’t room.
Here are more statistics on the program.
The center had 218 residents in its first two years. Each participating hospital had about 50 percent of its referred patients admitted. In its second year, only three percent of residents returned to the street; four percent to a shelter. In contrast, 64 out of 69 residents in its second year transitioned to housing or moved back with family.
Some residents do end up back in the hospital for something; others go to nursing facilities. Sometimes, residents don’t end up adjusting to life indoors, and leave before staff thinks they’re ready. Kohl recalls one resident, who was confined to a wheelchair, leaving the respite program before staff thought he was ready; he didn’t have his SSI, and didn’t have an apartment to go to. Kohl followed him into the street, as he was wheeling himself away.
“Please make different choices,” she pleaded, leaning against his wheelchair as he went.
He came back the next day.
Of the residents who do remain until the staff deems them “done”, 95 to 98 percent move into permanent housing, said Audrey Kuang, the center’s medical director.
Kohl likes to share the program’s success stories. William Mackey’s story is one of her favorites. He became homeless a few years after being laid off from a company he’d been with for 15 years. While looking for another job, he plowed through his savings, and ultimately lost his apartment. He lived in his car for a while, doing odd jobs. But without health insurance, or a home to prepare healthy meals, his diabetes progressed and he ended up with an ulcer on his foot. In the end, he required a partial amputation of his toes.
After that surgery, Mackey was referred to Santa Clara Medical Respite Center. He stayed for four months, time enough for his foot to completely heal. Plus, he was able to see a nurse at the EHC shelter’s clinic and that helped him get his diabetes under control.  Not long ago, Mackey moved into an apartment in Palo Alto, and is reportedly serving on Santa Clara’s Homeless Healthcare Advisory Board. He just received a Certificate of Commendation from the California State Assembly.
The National Healthcare for the Homeless Council reports there are over 60 medical respite centers around the country, and many more in development. “It’s exploding in the last few years,” said Kuang of the new model of care.
The Hospital Association of Southern and Central California is playing a key role in advocating for such programs in this area, because of their savings potential. Local governments and nonprofits like them too because they’re open windows of opportunity for residents.
“It’s a crossroads,” said Kohl “[It’s a time when] residents have a chance to change the trajectory of their path.”

By Isabelle T. Walker

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

Photo: Santa Clara County Medical Respite Center, by Isabelle Walker. 

On a morning in late August, 57-year-old Mary Manning (a pseudonym, at her request) was resting on her sister Jackie’s porch. She was midway through a rugged course of chemotherapy for breast cancer. Manning looked at her younger sister and said, “You know, I’m dying, sister. I think this poison is killing me.”

When Jackie went to check on Manning later in the day, she wasn’t at home. Calls to her cell went unanswered. Finally, at around 10pm., a nurse from Cottage Hospital called to inform her that her sister was in a bed on a medical ward there, receiving treatment for pneumonia, diarrhea and dehydration. “I went to visit her the next day and she was almost dead,” recalled Jackie. She said Manning was curled up on the bed in a fetal position.

After about ten days of acute care, Manning was released to Casa Esperanza. Like William Richardson, and other homeless hospital patients, Manning had nowhere else to go. The landlady who’d been renting her a room in a house near San Andres Street had recently told her she had to leave, that she was too sick to live there anymore. With only $600 a month in Social Security Insurance (SSI) coming in, there was little else she could afford in Santa Barbara, and Jackie, with small children to care for at home, couldn’t take her in either.

Because Manning did not sign a privacy waiver, some elements of this story haven’t been verified, including her diagnosis and the length of her two hospital stays. Yet both women clearly recall the afternoon Manning was discharged from Cottage Hospital. They said they arrived at Casa Esperanza around 4:30 but were quickly informed by the shelter’s staff that Manning was too weak to stay in a medical bed there.

Even though all the usual procedures for Cottage referrals had been followed – the paperwork had been sent over by discharge planners and approved by shelter staff – once they saw Manning in person the staff deemed her too weak to remain. She couldn’t get herself to the bathroom or the cafeteria without help.

“Take this piece of paper and go back to Cottage,” Jackie recalled shelter staff telling them. Manning was reportedly in tears. The nurses balked at re-admitting Manning to ER, but later, a doctor admitted her to a room and she remained there for another week receiving treatment. This time around, hospital discharge staff worked to get her a bed at a skilled nursing facility. Manning is lucky enough to have both Medi-Cal and Medicare, so she, unlike many homeless people, was eligible for a bed at Mission Terrace. Still, the bed was made available to her only for the time it took to build her strength up. After that, she would have to go back to Casa Esperanza.

That was the plan.

I met Manning the day after her arrival at Mission Terrace. She welcomed me to a room she shared with three others, and generously agreed to let me write about her situation for my project on medical discharges of homeless people.

Mary Manning’s fall into homelessness is at once unique and all too familiar. She’s a Santa Barbara native, actually. She grew up in a house near Las Positas Road, graduated from Santa Barbara High, and worked as a waitress on and off while raising two sons. But she lost her husband 15 years ago, and 12 years ago was diagnosed with breast cancer. She seemed to be out of the woods – but last summer, the cancer came back. The timing could not have been worse, as she had just lost the rental she’d had for years, when the property was sold.

Though a bed at Casa Esperanza was plan A for Manning after her stay at Mission Terrace, behind the scenes, caseworkers at Cottage and Casa Esperanza were working to get her into WillBridge. This small residence for mentally ill homeless people also accepts some homeless patients on discharge from the hospital, for recuperative care. Manning was hoping to go to WillBridge over Casa Esperanza, where instead of 30 roommates, she could have one.

But it was not to be. By Friday, September 9, Manning had regained enough strength to leave Mission Terrace. There was no bed available at WillBridge, so she was sent to Casa Esperanza and settled into the upstairs women’s dormitory.

A few days later, I dropped in to check on her. Slumped in a large armchair in the shelter’s cavernous lobby, wearing a down vest and leggings, she had a pale and resigned expression. Her purse was at her feet and the Nebulizer she needs to use five or six times a day for Chronic Obstructive Pulmonary Disease (COPD) was tucked next to her in her chair.

When I asked how she was she answered in a single word.

“Tired.”

When I asked if she felt she could get well here in the shelter she said, “No. Too many people. I’m just not used to it.” But then she paused and added, “Still, I’m grateful it’s here.”

Manning stayed at Casa Esperanza for a week. Each time I visited, she had the same resigned, tired, pale, and unhappy expression. On top of the difficulties of having cancer and being homeless and broke, she was also having to jump through hoops to get her medicine and the Nebulizer she needed to keep her lungs open. Apparently, Mission Terrace had not “aligned” her medication before discharging her to Casa Esperanza. She had some medication, but not enough to last her, and the Nebulizer they gave her was broken. When her meds ran out, the only refills available were through CVS for $110 – money she did not have. Ultimately, her prescription was filled through the county, and a Nebulizer was found, but only thanks to the persistent advocacy of Casa Esperanza’s medical coordinator, Jan Fadden.

On the 16th of September, a room at WillBridge opened up for Manning. Program Coordinator Nick Ferrara interviewed her first, and all the arrangements were made. Except . . . the day she was meant to move, she was once again out of medications. Ferrara could not safely allow Manning to stay there without medications vital to maintaining her breathing. So again, late on a Friday afternoon, Manning was directed to Cottage Hospital’s Emergency Room to get her medication. She was there several hours, but made it to WillBridge in time to spend the night. When I saw her on Sunday morning, she was wearing make-up and a bight pink sweater.

She said that living in close quarters with ten other people was taking some getting used to, but overall she was happy to be at Willbridge, where case managers would be helping her to get a housing voucher and other kinds of help. “Where it’s not just a dead end,” she said.

By Isabelle T. Walker

Sketch of Mary Manning by Ben Ciccati.

This article was conceived and produced as a project for the Online Community Building and Health Fellowship,  which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism. 

Clifton Jasper has come a long way since December, when he was living on the streets of Los Angeles, all but crippled by multiple ulcers on his legs. For eight years he tended his ulcers by himself on the streets, changing his dressings in bathrooms in public libraries and restaurants — any place he could find running water and soap. Emergency room nurses at Harbor UCLA Hospital helped him here and there, but the ulcers only worsened. Finally the pain became unbearable, he said.

On January 2nd, Jasper was admitted to Harbor UCLA hospital and kept for ten days. When he was deemed stable enough for discharge, he could have been turned back to the streets, like most homeless people. He could have been relegated to caring for his wounds in unsanitary sinks again. Instead, on January 18th, Jasper was discharged to the JWCH Institute’s Recuperative Care Program in Bell. There, he was given a clean bed in a small dormitory with other recuperating homeless men, 24-hour access to registered nurses and weekly check-ups with a physician. His dressings were changed regularly, his medication tracked and made available to him at the appointed times, and he was able to rest.

I met Jasper in August. He was sitting at the edge of his bed at JWCH’s Recuperative Care Center in Los Angeles, at the corner of San Pedro and 6th Street. It was mid-morning when the program’s manager, Dee Saupan, LVN, gave me a tour of the place. Jasper let me check out his small room. His legs were still bandaged up, but he was happy about the progress he was making. And with no family to lean on, he was clearly grateful to be there.

JWCH’s Recuperative Care program is the largest medical respite program for the homeless in Los Angeles County. And the oldest, too. It was started in 1991 when The JWCH Institute’s street outreach team recognized that a portion of Skid Row’s homeless, with large abscesses and other acute problems, were too sick even for a shelter.
So, according to JWCH Institute’s CEO, Al Ballesteros, the nonprofit began renting rooms at the Weingart Center — a 10-story building in the heart of LA’s Skid Row inhabited entirely by organizations and programs that serve the homeless. Today, JWCH’s Recuperative Care program has 23 beds on the second floor of the Weingart Center and 30 more in a newer facility in Bell. That’s 53 recuperative beds altogether. It has contracts with seven private LA County hospitals. Plus, all four County hospitals regularly refer patients who have nowhere to go. The center bills the hospitals $162 for each bed night the patient is in their program; that’s one tenth of what it would cost the average hospital to keep the patient overnight, said JWCH’s Recuperative Care Program’s director, Marcus Hong. Hong said patients discharged to JWCH’s program who stay until they get well have a 73 percent reduction in hospital inpatient stays, and a 32 percent reduction in ER visits. A third of them go into permanent housing, a third into transitional housing and a third are reunited with family, said one of the social workers.

The program basically allows hospitals to discharge the patients when they’re ready to be discharged, and not hold them over for want of alternatives.

The average length of stay for patients at JWCH’s program is 30 days, according to Hong, but some hospitals balk at paying for more than 10 days. Ballesteros says that attitude is penny-wise and pound-foolish.

“How do you put someone out on the streets or in a shelter in ten days?” he asked. In the end, the center ends up keeping patients longer, billing the hospital for as much as 30 days.

A dozen or more studies have established that medical respite saves money for acute care hospitals. A July 2006 study in The Journal of Public Health, for example, compared two groups of homeless people who’d been discharged from an acute care hospital. One group was accepted into a medical respite center on discharge, while members of the other group weren’t accepted into the centers because they were full. After 26 months, the study began keeping track of their hospital visits, and in 12 months, patients who’d been in a medical respite program spent 50% fewer days in the hospital than the ones who were turned away.

At JWCH’s Weingart Center location, some of the rooms are funded by the Housing and Urban Development department, and a handful are kept on hand as transitional housing, for patients who are well enough to leave, but have no place to go yet.  There are rules. Alcohol and drugs are not tolerated anywhere in the ten-story building. Patients on oxygen aren’t accepted because of the fire hazard. Sometimes, because patients have had addictions, they need to be convinced to comply with their aftercare, to take care of themselves.

Ironically, the patient dumping scandal of 2006 was what allowed JWCH to double its Recuperative Care program beds. When Los Angeles’ City Attorney charged Kaiser Permanente with elder endangerment, among other charges, for discharging a homeless patient to a shelter (put her in a taxi while still dressed in her hospital gown) Kaiser settled the case. Kaiser paid JWCH Institute $500,000, which the program used to construct a new 30-bed center in Bell. Those 30-beds positioned the program for a demonstration project that launched the same year.  Funded by the National Health Foundation, seven private hospitals in LA County collaborated to see if recuperative care could save them money. Though the funding wasn’t renewed after two years, all seven of the hospitals maintain contracts with the program.

While touring the place, I also met a guy named Larry. Larry was loquacious and outgoing and wheeled his chair up to me to praise the program.  He’d had three amputation surgeries (on the same leg) in a year, and will have one more soon. The 50-something man was effusive.

“It’s been a blessing. They’ve taken such good care of me. And she’s the nicest one,” he said, nodding his head in Nurse Saupan’s direction.

Larry is about to leave JWCH. Case managers found him a one-bedroom apartment in Valencia, near the Santa Clara River. Like every one of JWCH’s Recuperative Care patients who leave, Larry will be enrolled in The Center for Community Health, a big new health center that’s half a block up from The Weingart Center. It’s a primary care and social service clinic operated through a collaboration between JWCH, The Weingart Association, Los Angeles County, and a half dozen other agencies. That’s where Larry will go for his check-ups  and outpatient care. And just to make sure transportation isn’t an obstacle, the Recuperative Care program gives everyone Access cards when they leave, for free bus service.

By Isabelle T. Walker

Photo of Curtis Jasper and Dee Saupan by Isabelle T. Walker.

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

For two years, Bill Shea lived on the property of Christ the King Episcopal Church. As homeless camps go, it was average. He slept in a field, in a decent bag and with the blessing of the church’s rector.   He did not have the long arm of law enforcement to worry about at least. Plus, with a flow of Christians in and out, there was little risk of going hungry. He was surviving—if nothing else.
But then his survival came into question too. In August, Shea noticed he was winded after even small amounts of exertion. Thinking it would pass, he dismissed it. By mid-September, taking just a few steps had become a challenge, so he got some church friends to drive him to Goleta Valley Cottage Hospital (GVCH).

In the hospital, doctors discovered he had atrial fibrillation and congestive heart failure. He stayed there for six days; when discharge day came, he was released to WillBridge of Santa Barbara.

Unlike William Richardson and Mary Manning, two other homeless people I tracked after they were discharged from Cottage Hospital, Shea’s discharge was smooth as silk. Discharge planners were in touch with Nick Ferrera, the program manager at WillBridge, a small residence for homeless mentally ill people that also takes in homeless hospital patients. Ferrera knew all about Shea, his illness, and the day he would be released. That day was Tuesday, September 12th, and he invited me to come along.

A nurse wheeled Shea through the hospital lobby in a gurney-like contraption, and out to the WillBridge minivan. Ferrara helped him into the back seat.  Shea is a heavyset man with blue eyes and a light brown beard; how I might imagine a young Santa Claus to look, in the off season. Shea acted and looked tired, but he was willing to answer the many questions I had for him.

Shea came to Santa Barbara to finish college. He was moving steadily in that direction when his life fell off track. He remained vague about the reasons. He is reported to have had, at some point, an affinity for beer, perhaps even a fixation. Whatever it was that derailed his life, it was never something he could surmount. And then he landed at Christ the King.

As we were driving away from the hospital, Ferrara told Shea that we’d be stopping at the County Public Health Clinic before proceeding to WillBridge, to get the four prescription medications he would now need to take everyday. That process was held up at first by the news that Shea was not registered as a County Clinic patient. Yet, with Ferrara explaining to clinic managers that Shea could not get through the night safely without the medicine his doctors had prescribed for his heart, the three of us were quickly ushered into a side office, where Shea’s personal information was typed into the computer, rendering him officially “registered.”

At WillBridge, Shea was escorted by Ferrara to a small bedroom upstairs that overlooked a busy Santa Barbara thoroughfare. It would be the first night Shea would sleep in a bed (excluding the hospital bed) in over two years.

Ferrara ran down the house rules. No drinking or drugs of any kind; breakfast and lunch are self-serve in the kitchen and somebody named Dawn would stop by later to help with him with his meds. He could sleep as late as he wanted.

When I visited him the next day, Shea was sitting in the small downstairs den, watching television with two other WillBridge residents. His eyes looked heavy. He moved and spoke in slow motion. He said he’d slept well, and described the food as “okay.” He had a doctor’s appointment in the coming week, which WillBridge case managers would drive him to. His medicine made him feel weird, he said.

The following week, Shea’s responses were similar. I caught him smoking on the back patio once.

“I should stop,” he acknowledged.

Shea’s recovery proceeded like this for a month, slowly but steadily. He was given help filling out paperwork for Social Security Disability Insurance (SSDI)—a step towards permanent housing.

Then it all ended. In mid-October, Ferrara said WillBridge’s respite care funding was officially spent. The $20,000 that Cottage Health System (CHS) gave WillBridge to take its homeless patients discharged from the hospital in 2011 was exhausted for the year. Shea would have to move to Casa Esperanza. He would have to finish recuperating in one of their 30 medical beds.

And then he disappeared. Shea simply left the house without telling anyone on a Wednesday afternoon. Because it was locked up, he didn’t take his medication with him, either.

When Ferrara returned from a week off on October 24th, he immediately drove out to Christ The King Church. As expected, Shea had returned to his old stopping grounds and he was happy to see Ferrara, and soon learned that Christ the King was willing to pick up the tab for his respite nights at WillBridge. He could return that afternoon.

So things appeared to be back on track for Shea. He would get the time he needed to heal. He might even get a housing voucher. But less a week after returning to WillBridge, Shea developed an intestinal blockage. Ferrara took him directly to Cottage Hospital’s Emergency Department, where he was operated on.

When I called Shea at Cottage, he gave me the gory details of his surgery and illness and said doctors weren’t predicting a discharge date. But at least now, thanks to his church, he willl have a place to go.

By Isabelle T. Walker

Sketch of homeless man by Ben Ciccati.

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

Cindy McCallum said the two nights she spent on a grassy knoll opposite the Santa Barbara Rescue Mission were the scariest she’s lived through. The 53-year-old disabled homeless woman doesn’t say much about the night before she ended up across from the Mission — the night she wandered the streets and stayed, at least part of the time, in the hospital’s parking garage. That was the night of October 28th, when the homeless shelter Casa Esperanza sent her to Cottage Hospital’s Emergency Room to be checked out for a possible stroke. It was the night she was discharged by ER staff to The Santa Barbara Rescue Mission with a bus token. Some details of what happened to McCallum between that Friday evening and the following Monday, October 31st, are still unknown. What is known is that McCallum — who is cognitively impaired in addition to being partially paralyzed from the effects of a stroke — spent an entire weekend outside, predominantly alone, unable to get up off the ground without assistance, use the bathroom or defend herself if she needed to. Her nightmare ended when a fellow homeless woman spotted her on Monday morning and called 911. She was brought to Casa Esperanza in a Santa Barbara police squad car.

McCallum’s ordeal, which came to light through an anonymous tip, is a stark example of what can happen to uninsured homeless residents in South Santa Barbara County after a hospital stay if they are too medically fragile for a homeless shelter. McCallum, who does not drink or use drugs, plunged into a cavernous gap in services here when she was brought to Santa Barbara Cottage Hospital this summer after suffering two strokes. She does not know how she got here, only that she left her sister’s home in San Luis Obisbo County in June to attend her daughter’s graduation from college in Long Beach. On July 4th, she said, she suffered two strokes. Her daughter brought her to an acute care facility, but she somehow ended up in Santa Barbara and began receiving care at Cottage Hospital.

Sources at Casa Esperanza said McCallum was discharged from Cottage Rehabilitation Hospital to their facility around the 24th of October. But shelter staff said when they approved her for a medical bed, they did not know she was unable to dress or shower independently or that she was often incontinent.

Casa Esperanza does not accept hospital patients unless they can dress, shower, and ambulate independently.

“Every morning I wake up wet and then I start crying,” McCallum told this reporter.

Cottage Hospital received a privacy waiver signed by McCallum freeing them to disclose information about her discharge and care. Last Friday afternoon, November 4th, Cottage spokesperson Janet O’Neill said McCallum’s case required further internal review before any information about her case could be released.

According to sources at Casa Esperanza, McCallum’s nightmare began Friday afternoon, October 31st. Between 4 and 4:30 pm, a staff member suspected McCallum was having a third stroke and sent her to Cottage Hospital’s Emergency Room by ambulance. A  shelter staff member then called the ER to alert them McCallum was on route and instruct them not to discharge her to the shelter because of her great level of need. According to shelter sources, three hours later, ER personnel called the shelter and requested that McCallum be returned to Casa Esperanza. The shelter staff member said she could not.

Around 7:30 pm that evening, McCallum was seen on the street near the hospital, requesting directions to the parking garage. The next known interaction with McCallum took place that morning. McCallum said while in the parking garage, she bumped into a nurse she recognized from Cottage Rehabilitation Hospital. The nurse reportedly invited her back to that hospital where she gave McCallum a sandwich and bottle of water. At some point soon after, County Adult Protective Services (APS) was called to assist, apparently, because an APS case worker is noted as having called Casa Esperanza around 11 am asking if McCallum had a bed there. Again, the answer was no.

A staff member of the Santa Barbara Rescue Mission named Eddie Tyrell said during his Saturday shift, an APS case worker came onto the premises and explained she was leaving a homeless woman with slurred speech across the street. (The Rescue Mission does not begin letting residents inside until late afternoon.) Tyrell asked the case worker if the woman had been medically cleared to stay there, to which the APS worker responded she had. But Tyrell said he was unaware of McCallum’s paralysis and cognitive disability, so he did not check on her during the day. Knowing now just how disabled she was, he said he regrets not doing so. But, in the end, McCallum never crossed the street to seek shelter. Besides being unable to get up off the ground without assistance, McCallum didn’t understand the rules and requirements of the Rescue Mission. It’s unclear if help was offered by other homeless people or whether McCallum refused it.

Sources at Casa Esperanza said what McCallum requires is a skilled nursing facility (SNF). Yet no SNF in Santa Barbara admits uninsured people and, in addition, all SNFs require a physician to initially admit them and oversee their care.

Cottage Hospital spokesperson Janet O’Neill said ER staff discharged McCallum to The Rescue Mission on Friday, October 28th.   She was offered a cab ride, but declined it because she said she does not like to accept special services if she can get by with less. So she took only a bus token and recalled her plan to walk back to Casa Esperanza. She even asked a security guard for directions, she said. But she went to the parking garage instead because that’s where she left her purse weeks earlier when she was first admitted to the facility.

In an interview this summer, Todd Cook, Cottage Hospitals director of Care Management, said the hospital does not discharge homeless patients unless it can be sure it will be a safe handoff. In this case, that standard appears not to have been adhered to. This year, the hospital is giving Casa Esperanza $39 for every night one of their patients spends at the shelter, up to $150,000.

When a police squad car brought McCallum to Casa Esperanza Monday morning, witnesses said she was unable to get out of the car unassisted, was soiled, cold and frightened. Staff reportedly helped her shower and gave her clean clothes. She is staying again in a medical bed, though her needs remain beyond what the shelter can provide. Staff is pitching in to help where they can. Meanwhile, McCallum spends the bulk of her day curled up on her bed in the women’s dorm. She seems bewildered as to how she managed to end up in a homeless shelter.

“What amazes me is how fast it all happened,” she said, recalling the July day she had her strokes. She remembers walking down the street with her daughter, looking for a place they could both get a pedicure. Apparently, they never found one.

By Isabelle T. Walker

Photo of Cindy McCallum by Paul Wellman

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

In a perfect world, when a homeless person is discharged from the hospital and still too fragile for a homeless shelter, he or she could go to a skilled nursing facility (SNF). There, they could get help with bandages and medication. They could recuperate fully before returning to the hardships of street life.

Sound logical?

Unfortunately, in South Santa Barbara County, SNFs are rarely an option for the homeless. And it has everything to do with money.

All the SNFs in South Santa Barbara County require residents to have health insurance, or at the very least Medi-Cal. Sometimes even Medi-Cal isn’t enough for a skilled nursing facility to accept a departing hospital patient. If they’re particularly medically needy, for example, or young. On top of that, every SNF resident needs to have their own primary care physician looking in on them now and again, overseeing their care. Yet few primary care doctors in Santa Barbara will accept the paltry reimbursement Medi-Cal pays for a nursing home visit. It’s not worth their while.

It’s been suggested that, in a pinch, perhaps medical directors of the various nursing facilities could step up and take these orphaned patients, becoming the doc of last resort. Yet these days, few if any of them will do so.

It’s a problem.

Take Cindy McCallum, the partially paralyzed homeless stroke victim profiled recently on this blog. She could sorely use such a facility now. Incontinent, unable to dress or shower independently, McCallum’s needs are way too great for the staff of Casa Esperanza, or any homeless shelter, which is swamped with the chaotic, non-stop issues that arise when you crowd 100 homeless residents together in one building.

Cottage Rehabilitation Hospital discharged McCallum to Casa Esperanza because they couldn’t find an SNF to take her. There was no place else to send her, apparently. Either that or they didn’t look hard enough.

According to Ralph Barbosa of the County’s Healthcare for the Homeless Program, 26 percent of the 5,309 homeless patients the County treated in 2010 had Medi-Cal.  That means about a quarter of the county’s homeless population could ostensibly qualify for a nursing home stay. If only there were doctors willing to look after them while they’re in there.

Dr. Dennis Baker, a primary care physician and Casa Esperanza board member, said little effort has been put into finding a pool of doctors to follow homeless patients into SNFs. In other communities, including Los Angeles, medical residents provide this service as part of their training. Dr. Brian Prestwich, Chief Medical Director of USC’s Eisner Family Medical Center, said the USC’s Family Medicine Residency Program has a nursing home teaching service. Working under the supervision of an attending physician, residents go out to nursing homes to see their patients who’ve been sent there.

One would think this could work in Santa Barbara too. Already residents training in Cottage Hospital’s Internal Medicine Residency Program provide care to both indigent and Medi-Cal patients at the County Public Health Clinics. But Dr. Andy Gersoff, who runs the program here, says it’s complicated proposal. The residency program here is small, having a small faculty and no affiliation with any of the SNFs in town.

“The role of Cottage Hospital, I don’t see as necessarily to provide care for people in nursing homes,” Gersoff said.

Meanwhile, up in Santa Maria, Dr. David Lennon,the County’s Healthcare for the Homeless Medical Director, is providing this service to homeless patients. With privileges at various SNFs, he follows his homeless patients to them.

But down in the South County, the Public Health Clinic’s doctors are stretched too thin to take on that additional duty, said County Public Health Department’s Deputy Assistant Director Susan Klein-Rothchild. However, she added, the department is exploring different ways that it could begin providing that service here.

Darien Smith, an executive at Compass Health, which just purchased the de-licensed Central Coast Nursing Center, said he would be happy to discuss a possible collaboration with the Cottage’s Internal Residency program.

“If the residents wanted to come and talk to us, we’ll talk to them,” said Smith. But in the meantime, patients like McCallum will continue to be placed in the wrong setting or, worse, no setting at all.

By Isabelle T. Walker

Photo of Mission Terrace nursing facility by Paul Wellman

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

Michael Stowell’s relief is palpable. Sitting in the courtyard of Casa Esperanza, a wooden cane leaning against his lap, he smiles broadly. It’s been a long time since he could smile like that.

Sixty-year-old Stowell hobbled around Santa Barbara on that cane for nearly a year, his left leg pivoting on a partially dead hipbone. A repair job in 2009 used pins to attach the hip’s ball to the adjacent bone, but ultimately failed. Three weeks ago, after waiting months for the pieces of the County’s indigent healthcare system to line up, he got it replaced. It was a four- hour-long surgery, he said, and kept him in Cottage Hospital’s med-surg unit for two-and-a-half days.

Stowell is one of those people you look at and wonder, ‘Why is he homeless?” He doesn’t drink or take drugs. He’s obviously bright. But he definitely had a string of bad luck. In July, 2009, while riding his bike to the Employment Development Department, he took a curb the wrong way with his front tire, flipped over the handlebars and landed on his hip, breaking it.

Just two weeks before that, he’d been laid off from a job with the Austin-based firm Second Meta. He’d been writing HTML code for them, telecommuting from his Goleta rental. Suddenly, he was collecting unemployment, along with a handful of his Second Meta colleagues. But the hip injury made him ineligible for work, so he applied for California State Disability. That came through, but wasn’t enough to cover rent and food. As luck would have it, by time he was well enough to work again, he was homeless.

Stowell’s story, like the stories of so many homeless persons here and across America, illustrates how connected homelessness and illness are; they go together like clouds and rain.

Last spring, while sleeping on the floor of the Rescue Mission, gradually figuring out why his hip hurt so much and what to do to access care without insurance, Stowell developed a hernia—the kind that can rupture. Now, instead of one surgery on the horizon, he was looking at two.

Stowell actually got lucky. Both surgeries were devoid of complication and both hospital says concluded with smooth discharges to Casa Esperanza. Each time, he was given a voucher for a cab ride to Casa Esperanza, after an initial stop at the County Public Health Clinic for medication.

After his hernia surgery, Stowell was still experiencing pain from his hip, taking Norco painkillers throughout the day to keep it in check. He availed himself if the shelter’s bed rest policy; that is, he got a full week of unlimited bed rest in the men’s dorm following his hernia repair. When the week was up, he was told he’d have to be up and around during the day with the rest of the residents. Stowell was not happy about it. Ultimately, opting to leave his medical bed and move to the Rescue Mission. There, he slept on a mat on the floor of their chapel, hobbled to the library after breakfast, and kept checking his mail at Casa Esperanza, looking for word on the scheduling of his upcoming hip surgery.

I kept asking Stowell where he planned to recuperate after the hip replacement. It’s major surgery after all. The Rescue Mission, where he didn’t even have a bed, seemed hardly the place to do it. But he kept answering that it would be Mission. He wasn’t going back to Casa, obviouisly, still mad about the whole bed rest incident.

But in the end, he didn’t have to. On the day of his discharge from Cottage, Jan Fadden, Casa’s Medical Coordinator and a saint if there ever was one, came to see him. She assured him he could have as much bed rest he needed; however long it took, he could rest upstairs.

Yet, tt was bed rest he did not end up needing. Within a few days of his discharge, Stowell’s hip pain was nearly gone. He used a wheelchair for bus rides to and from the County Public Health Clinic, but otherwise relied on a walker, and eventually, graduated to a cane. He understood the less time spent in bed the better.

At first, Stowell was giving himself injections of Luvonox twice a day. He kept his medication with him upstairs, but relied on the Casa Esperanza nursing staff for blood pressure checks. He got pretty good at it.

This week, Stowell began physical therapy. He’ll need it twice a week for six weeks. He says these last two years, the experience of chronic pain, and homelessness, and the intransigence of bureaucracies, have made him stronger. He’ll be back on the job market by January.

By Isabelle T. Walker

Photo of Michael Stowell in Casa Esperanza’s men’s dorm by Paul Wellman.

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.

For the past six weeks, as part of an Annenberg School For Communication Online Community Building and Health Fellowship, this blog has been looking at what happens to homeless people in Santa Barbara following a hospital stay. Few people are truly well after being discharged from the hospital; many remain fragile and weak for weeks.

I followed four homeless people who received care at Santa Barbara Cottage Hospital and were then discharged to one of two nonprofit homeless agencies: the large Casa Esperanza homeless shelter, and the smaller WillBridge of Santa Barbara. Two of these four people had smooth transitions.  Two were bounced between WillBridge and Casa, and back to Cottage Hospital’s Emergency Department, because neither environment was suitable.

Then there was the sad debacle that followed Cindy McCallum’s visit to the ER last month. With partial paralysis and a cognitive disability, McCallum was discharged with a bus token to the Rescue Mission, but never made it there. Instead, she spent the next three nights outside, unable to see to her most basic needs.
To conclude this series, I sat down with Cottage Health System’s Chief Operating Officer (COO), Steve Fellows. I wanted to know if he’d read this series and, if so, what he thought. Mr. Fellows was generous enough to give me 40 minutes of his time right before the Thanksgiving holiday. Though we disagreed on several points, our discussion was lively and thorough.
Right now, the efficiency of medical respite centers for homeless individuals is being recognized throughout the country. This is because they save lives and reduce future hospital stays, thereby also reducing costs. It’s too early to know if Santa Barbara will consider creating such a facility, but it’s obvious there is a need for something along these lines here.

Think of William Richardson, a 44-year-old man who collapsed on State Street because of soaring high blood sugar. How much could he have benefited from the stability of a respite care center, with nurses available 24-hours a day, as he was learning to check his blood sugar and inject himself with insulin for the very first time? Think of Cindy McCallum, who repeatedly awakens in her bed at Casa Esperanza wet and humiliated. Our community deserves better. Our community deserves some system, or facility, where its most vulnerable residents can recuperate from illness with a measure of peace and dignity.
Thanks for reading.

Steve Fellows Interview

ITW: Have you read any of the articles in my series?

SF: I did. I’ve read a few of them and I read them either online or in The Independent. 

ITW: What did you think the content? Did you learn anything? Or did anything surprise you?

SF: What I noted was that you pointed out gaps in the system that I thought were issues that we as a community I think need to be concerned about. What I didn’t see and what was surprising to me is that I didn’t see mention of all the community-wide homeless collaboration resources that are underway in our community.  For example, there’s a group called The Homeless Roundtable that meets every Monday here at Santa Barbara Cottage Hospital; it’s a coalition of numerous community organizations and agencies that come together to address the homeless challenges. There’s Common Ground, another group that we participate in. I don’t know if you might be aware, there was a meeting last week up in Solvang that Cottage participated in, along with a number of other agencies, called the Summit on Homelessness, which was really looking at creating some kind of a model to try and address some of the homeless needs and issues in the community.

ITW:  I was actually at that meeting and I’ve written extensively on the Common Ground campaign. And I did  know about the Monday meeting. It would have been a good thing to mention it, but in terms of the people I have been following, I haven’t discovered anything that’s come out of that meeting for the people I followed.

SF: Well that’s disappointing because there is a tremendous amount of work that goes on with those groups.

I think the other perhaps important information that you might find helpful is that our residents in our medicine and surgery residency training programs . . . our residents and faculty staff the county clinics and provide that care to the county clinics. And so when I look at all the resources that we as an organization provide back to the community, it really suggests that what we are doing, or trying to do, is from a position of our mission, if you will, as an organization, which is to provide the very best care that we can provide through our core values of excellence, integrity and compassion. We really are an organization that’s all about providing care and a group of individuals whose really sole purpose and focus is providing a compassionate environment for the needs of our community. We serve a very broad constituency, it’s not just the homeless, but it’s a very broad constituency of the community. So on any given day, we’ve got 3,000 employees, 500–plus physicians, 850 plus-or-minus volunteers who come into our facilities everyday to provide care and resources and services to our community because we are a people of compassion and we want to make a difference. So whether you’re the CEO or the COO of the organization, or you’re a direct patient caregiver at the patient’s bedside or you’re one of the staff that’s supporting the efforts and endeavors of moving supplies throughout the campuses for patients, it’s really what we are about.

And we provide what we think is a very important resource and safety net within the community. But we don’t do it alone. We do it with a lot of other people. 

IWK: Cottage is amazing hospital. It truly is. But it’s also a monopoly and it also took over the duties of the County Hospital. So you do a fantastic job, but my focus in this series is what happens to homeless people when they’re discharged from the hospital, and the fact is, I have discovered through my investigation that it’s not always done well. And so I wanted to find out, from you, what do you think about some of the things I’ve written about? Do you think they could have been done better? For example, did you read the story about Cindy McCallum? Maybe you can comment on that one.

Fellows: I don’t remember the detailed specifics of each of the individuals that you’ve written about. But here’s what I can say. First of all, we acknowledge that we’re a sole provider in the community, and as a sole provider, we have an important role and responsibility to our community. We are a public trust, right?  We are a community benefit. We take that responsibility very seriously.  And so when individuals arrive at our Emergency Department we don’t ask whether you have insurance, we treat. 

ITW: Well, that’s the law. If you did ask, you’d be breaking the law.

Fellows: But that’s what we do. We do it because we believe it’s the right thing to do. Someone shows up in our organization, somebody shows up in one of the emergency departments, and they have a need, we meet that need. We don’t turn people away. If that same individual needs to be admitted to the facility, we admit them. We admit them. We take care of them and then we prepare for their discharge. And their discharge is coordinated by dedicated care managers and by social workers whose job it is to coordinate their discharge and proper placement. Some individuals need placement in hospice because they’re nearing end of life. Some individuals need placement in a skilled facility for a short period of time, perhaps even a long period of time. Some individuals are prepared to go home. And go home with appropriate caregivers. Some individuals don’t have anywhere to go, particularly the homeless, they don’t have anywhere to go, so we’ve established relationships with various organizations out there to provide those resources that meet their specific needs post-discharge. So when you’re in the hospital, you’re in the hospital because you meet the criteria for acute inpatient stay.

When you no longer meet that criteria, then we provide an appropriate environment for the individual to go to. So: Casa Esperanza, through the respite care program. WillBridge, through a similar kind of a program. Or Sarah House or VNA [Visiting Nurse Association] for hospice care. So we’ve established those relationships, we provide funding to those community organizations because they do good work, and we help meet their needs and we help meet their mission and help meet their goals by providing these resources in the community. 

IWK: That is true. But what my series has uncovered is that sometimes, I think, what you’ve provided, with all good intentions, has not been adequate. For example, the money that you gave Willbridge for this year, I’m not exactly sure if it’s fiscal year, or calendar year, my understanding is that Cottage paid Willbridge $20,000 tops for providing respite care for the entire year. Well that money ran out at the end of October. So right now, when your discharge planners are working hard to find a place to place these people, including someone like Cindy McCallum, Willbridge is not an option.  Why may I ask would Cottage give that kind of funding to Willbridge, so it would run out in the middle of the year?

Fellows: So the process that we go through every year is, we engage community organizations and community agencies in a discussion. We did that with Casa Esperanza, and I’m happy to answer your questions about Casa. We engage them in a conversation. They say to us, we need x for this year. We go through a process with them of discerning what their needs are and we come to an agreement on the funding for their program, or for the resources that they say that they need. So that’s the process we go through. We agree to a certain level of funding. This year, our funding is well over give-or-take $225,000 for various organizations throughout the community. We’ve got a community grant program that we provide funding for.  A pretty extensive community grant program.

IW: Does that come from the Foundation or the Hospital?

Fellows: No, the hospital.

Janet O’Neill: It’s $780,000 in grants in 2012. 

Fellows: Isabelle, are you aware of our Medical Need Non-Emergent program that we provide for the community? 

ITW: I’m pretty familiar with that, and I’m sure that it’s laudable and incredible. As I say, Cottage is an amazing institution. I’m talking about this one aspect of its service. Have you read any of the research on medical respite care and the financial benefits hospitals receive from medical respite centers?

Fellows: I’m not familiar with that. 

ITW: There’s a growing body of research.

SF: Is it research or is it … Tell me about it.  

ITW: It’s research published in major scientific and medical journals, including JAMA [Journal of the American Medical Assocation] and The Journal of Public Health.  If there is a respite care center, a place where homeless people can be discharged to post-acute care, where they have round-the-clock nursing care, the people who go there have fewer inpatient stays at the hospital in future years. So it actually ends up benefiting hospitals.

Fellows: No. I’ve not seen that research. The work that we do with Casa Esperanza has actually been in the last year a four-fold increase in support of Casa. And there are a number of organizations and agencies in the community that support that effort. The St. Francis Foundation provides support through the Parish Nursing program. The county Public Health Clinics also provide funding in support for the program. There are individuals that are there through the night with the patients, so patients aren’t there alone. Casa ‘s been great in allowing these patients post-acute to not have to leave the facility during the day, and then come back in the evening. So they allow them to stay there. 

And I think that what we’ve tried to create is a partnership with a number of agencies in our local community. And so when you think about it, it’s not just one organization who’s providing resources, it’s multiple organizations who are coming together who have a common mission here of providing post-acute care for individuals in our community. So, whether it’s Cottage or it’s the St. Francis Foundation or it’s the County of Santa Barbara or it’s whomever, you’ve got a coalition of individuals who are coming together with a common purpose. 

I don’t know what’s happening in other communities everywhere else in the country. I just don’t know what every different community is doing. I know what we’re doing in our community. And I think that the gaps that you’ve pointed out in your article suggest that there are opportunities for us to work together as a community to help to resolve those. I do think that there’s a potential here with the Summit that might help to address those kinds of questions in the future.

ITW: So do you think what Cottage is doing right now, in terms of the medical discharges of homeless people, in terms of its support of the facilities and also its processes, the processes it has in place currently for discharging people who have no place to go, do you think they’re adequate right now?

Fellows: I think that the process of preparing individuals for discharge is state of the art. I think it is equal to what you would find anywhere else. It is the same process for the homeless as it is for Steve Fellows if he were being discharged from the hospital. It’s the same process. The challenge that you face is in placement post-discharge. So I want to differentiate the two, if I may please. 

The process is the same for everybody. The challenge post-discharge is based upon the individual’s needs, and having the resources even available in the local community. So Casa Esperanza is, we would like the discharge to Casa Esperanza for the individual who needs that home health care level of care and service. I don’t know a lot of my colleagues elsewhere in the California or the country that have any kind of a relationship of that nature and actually pay for those resources and services. 

ITW: That’s surprising because they’re all over California.

Fellows: There are different models. So the model that we have deployed in Santa Barbara may be a different model than that deployed elsewhere, but I’m not aware that the model that we’ve deployed in Santa Barbara is inferior from what you’re suggesting to the models that are deployed elsewhere. 

IW:  I’ve visited various places around the state and what we have here does appear to be inferior.

SF: So tell me about that. 

ITW:  Many cities and towns around the state have places where hospitals can send their patients who have no home when they are particularly medical fragile. These are centers with round-the-clock nursing care, and where they can stay until they get well or are placed in housing.

O’Neill: Who runs those? 

IW: Sometimes nonprofits. They’re freestanding centers, where the area hospitals pay by the bed night for the individuals who are sent there or they pay a flat fee annually which entitles them to send people there throughout the year. And what happens is that the people who are sent there are kept there until they are well or at least stable.

Fellows: So we have an opportunity to take a look at those options available to us, whether it’s through the Summit — we have an opportunity to look at the same in our local community. Cottage is at the table. Cottage has agreed to participate. And I think that this is a community challenge. This is not a specific organization or community agency challenge. I think this is a community challenge. And it takes an entire community coming together and addressing these issues and then coming up with the best strategy to respond.  

ITW: I agree with that. However, Cottage is in a unique position in that it has the resources to — basically to solve some of these issues, whereas the community organization don’t’ really. And the fact [is] that it was once the County Hospital and thus has a responsibility for those who are most vulnerable. In some ways it comes down to a moral imperative. Do you think Cottage has a moral imperative to do more?

Fellows: We may depart here at this point. Cottage has a responsibility to be available to respond to emergency needs in its community. To be available for acute inpatient needs. Cottage needs to respond to those in the community who have short-term post-acute care needs. But Cottage can’t provide all of the long-term chronic care needs of the community. That’s not what we do. We need to be able to collaborate with others in the community. We need to be able to collaborate with Santa Barbara Neighborhood Clinics and with the American Indian Health Service Clinics, we need to collaborate with the County of Santa Barbara. ‘Cause what I’m hearing you say is that Cottage has a responsibility to take care of everybody’s post-acute care. And that’s not what we’re about. We are an acute care facility. And so we need to take care of those acute care needs but we cant’ take of those lifelong chronic needs because we don’t have the ability to do that.

ITW: I didn’t mean to say that Cottage needs to take care all of the long-term healthcare needs of our homeless residents. I was asking if Cottage has a responsibility to do more than other community agencies.

Fellows: That’s what I heard you say . . So maybe I misunderstood. 

O’Neill: It really is a difference between the chronic and the acute. And the chronic needs to be dealt with in a more collaborative way.

ITW: Well my main interest is the discharges. What is Cottage’s responsibility when it comes to making sure that people who have no homes have a place to recuperate? Does Cottage have a responsibility there?

Fellows: There are probably two options. You either keep the individual in the hospital longer than they might need when it comes to acute care services and resources, or you have options for the discharge of patients outside. 
I believe, we believe, that through the relationship we’ve established with Casa Esperanza, the work and partnership with St. Francis Foundation and Parish Nursing, the work with the County of Santa Barbara, we’re providing a resource in our local community so that our homeless when they are discharged from an acute care environment go to an appropriate environment. 

ITW: But that’s not always the case. Casa Esperanza is not always appropriate. Sometimes people who are too medically fragile are sent to Casa Esperanza.

Fellows: Based on whose perspective [is it] that the patient was not appropriate for transfer to Casa?

ITW: I think if you asked the average person walking down the street they would probably say somebody who is not able to get themselves to the bathroom, for example, should not be transferred to Casa. Somebody who has no knowledge of how to administer a life-sustaining drug. Those people would probably not be appropriate for a homeless shelter that only has CNAs [Certified Nursing Assistants] at nighttime and RNs [Registered Nurses] part of the time during the day.

Fellows: So I would offer a couple of things for your consideration. First of all, when it comes to preparation for discharge planning, that’s a role that the clinical staff play. The evaluation of the patient . . .  patients are not discharged, if you will, by the hospital. We don’t admit or discharge patients. Patients are admitted and discharged by an attending physician. They are the only ones who can admit or discharge. So it’s a clinical judgment as to the patient’s readiness for discharge. We make the arrangements based upon the conversations with the clinicians. And then the patient is prepared for discharge. And then we seek to place the patient in the proper post-acute environment. 

IW: What if there is none?

Fellows: Let me say this, when there may be a lack of the appropriate environment to place an individual, I am not aware that we discharge them. I’m aware that we keep them in the facility until we find an appropriate environment for discharge. And I suspect that if I went back and looked at data, I would bet that there’s data that show patients with very long lengths of stay because there wasn’t an appropriate environment for placing them. Or they required ongoing care and treatment that couldn’t be provided at Casa Esperanza. Or we couldn’t find placement for somebody at a skilled nursing facility because the individual had no insurance, and of course a skilled facility is not going to take them; and they don’t qualify for Medi-Cal and they don’t qualify for Medicare and they don’t qualify for some other payer. I am aware that we have had people in this facility for weeks and sometimes for months because we didn’t have proper placement for them. What happened to those individuals? They never had a payment source and Cottage wrote those bills off. We took care of them because taking care of them was the right thing to do. So we make the very best effort to determine the appropriate placement for someone. 

I would simply offer that there are times where a patient gets discharged from the hospital and everybody believes that the patient was ready for discharge and something happens. The patient has an unfortunate experience at home or at the skilled nursing facility because we all react differently to medical treatment. No two of us are the same. 

So you have a patient who reacts differently post-discharge and they wind up being readmitted to the facility. Was there a problem with the discharge? Maybe, maybe not. But what we discovered is that that individual had a problem that needed to be addressed. So is it a perfect system? I don’t know; probably not. But I guess my concern or my perspective is that it sounds like we’re looking for perfection and I don’t think there’s any perfect system out there.  I think that everybody is doing the very best they can based upon the patient’s needs and preparing them for discharge and discharging them to the best environment.

ITW: I truly believe that’s what Cottage is intending to do but I do not believe from what I have discovered in covering this issue as a reporter that that is actually what’s happening. For example, right now WillBridge is not an option because the grant out in October.

Fellows: Can you help me understand why the grant ran out in October? Your understanding of why the grant ran out in October.

ITW: Whatever mechanism Cottage set up with WillBridge was not adequate to meet the needs of hospital discharge planners who need places to send  [homeless patients].

Fellows: So let me take us back to that original conversation. Every year organizations submit their needs to us. They submit their requests to us. We review those requests and we come to an agreement with them on their need and then we provide the funding accordingly.

ITW: So what you’re saying is that Willbridge did not ask for more than $20,000?

Fellows: I don’t know what WillBridge asked for because I’m not the individual that negotiated the discussions with WillBridge.  I would need to find out what happened with that. 

ITW: So my question to you is that, if Cottage takes seriously its mandate to discharge homeless people to someplace that’s safe, when WillBridge became off the table because of no funding, why did Cottage not address that? Why did Cottage not call WillBridge and say we need to be able to discharge people to your facility because there are only two places to discharge homeless people to in Santa Barbara. Why didn’t Cottage bring that alternative back?

Fellows: You’re asking me a question that I don’t have an answer to you because as I said I am not the party who negotiated that arrangement. So I don’t know the specifics and details behind the WillBridge [grant]. I do know the details behind Casa Esperanza because I was at the table at Casa Esperanza. But you bring up a question that I will do a follow up on. I don’t know. 

ITW: You were saying there’s no perfection and that everybody is doing the best they can, and I was saying that although people may think they’re doing the best they can, I don’t think they’re doing the best they can, just by looking at the results. And I’m giving you an example of something that’s very fixable.

O’Neill: Do you think WillBridge underestimated what it needed? 

Fellows: Or perhaps we underestimated what we needed? 

ITW: Where does Cottage feel like they have a responsibility? Does Cottage feel if there isn’t a safe place to discharge homeless people to, that it should take an active role?

Fellows: Cottage has taken an active role. It’s Cottage that sat down with WillBridge and looked at the needs. It’s Cottage that sat down with Casa Esperanza and looked at the needs. It’s Cottage that sat down with many organizations. We’ve been seeking to work with the community. We sit on numerous community task forces. We are at the table with our community. If we were simply reacting, we wouldn’t be at the table. So I’m going to disagree with your premise. I’m going to disagree with your premise that Cottage is simple reacting. We are not simply reacting. We make a concerted effort to coordinate the needs of the community with the various agencies in the community. But I’m not sure you believe me. 

ITW: Well, Mr. Fellows, I appreciate your time. Thank you very much for answering my questions.

This article was conceived and produced as a project for the Online Community Building and Health Fellowship, which is administered by The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communcation & Journalism.