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.