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.