Patients being discharged prematurely

OnlybyHisgraceRN, ASN, RN · Apr 26, 2012

I used to work in LTC and seen this quite often with the elderly. I will never forget about the patient we sent to the hospital for them to send him right back.

He wasn't back in our facility for 5 minutes before we had to call 911 to send him back to the hospital. He had a major GI bleed upon returning to the hospital and loss 500 ml of blood.

Needless to say, that ER heard a mouth full.

Vespertinas · Apr 26, 2012

When can the hospital stop supporting the patient? If the patient is eligible for medicaid, a social worker steps in to begin that process. If they're not, the hospital does its best to give treatment, prescriptions, DME, and education. Your homeless man knows where the homeless shelters are and those places can link him to services to help get his life on track. It would be lovely if we could fix all the problems for everyone who has been admitted but a hospital is a HEALTH care facility.

Patti_RN · Apr 26, 2012

I'm very involved with under- served populations and have volunteered for and started organizations to support the homeless. Shelters are most often day facilities offering food, showers, or job training, or they are overnight facilities where you check-in at 8 PM (if there are still beds available) and you must be out early in the morning. Women/ children shelters are more often longer-term. These places (often run by church groups) simply cannot care for seriously ill people. I don't advocate allowing anyone to stay beyond their treatment period, but discharging anyone to the sidewalk is unconscionable--especially when the patient's medical condition warrants hospital (not respite) care. This is a failure of our society, a failure of social services, and a failure of the hospitals. The failures are not premeditated cruelties, but rather caused by financial constraints in an a sector that should have greater public funding.

nurse2033, MSN, RN · Apr 26, 2012

I'm not up on all the details but Medicare regs are now tracking hospital readmission and I believe they won't pay (as in the case of medical errors) for care received on the readmission. This will probably make discharges more conservative. In my experience (mostly suburban hospitals) DCs are delayed. The patient is ready but the MD hasn't had time to come around and do the paperwork.

Vespertinas · Apr 26, 2012

I am going to come off like a callous person for saying this but... we are already stretching our budgets to the limit by giving homeless people any care at all! That extensive surgery that he got probably cost oodles! 'Putting someone out on the sidewalk' is basically returning them from whence they came. I love when patients indignantly ask me "well how am I going to get home?" upon discharge. The same way you came in, my friend! Just because you've been an inpatient doesn't mean I'm now responsible for your entire life.

Okay, okay- your patient should have stayed longer, an early discharge is a dangerous thing. I work at a Catholic hospital so we treat our homeless patients like gold.. and there are enough to go around. But with the small margins of profit that hospitals struggle to make, sometimes I really wonder how my hospital manages to keep its charitable approach.

I have been in situations where I felt a patient was getting discharged inappropriately. I've stood n the way many times. Sometimes the MD's aren't really aware of the situation as much as you are so.. clue them in! Some MD's can even be grateful for it.

Esme12, ASN, BSN, RN · Apr 26, 2012

But the elderly man/woman with no family came by ambulance, He can't drive anymore because they took his license....his vision is poor. He lives alone and doesn't attend church. how does he get home? Who looks after him? Do we toss him aside because he's a burden?

I know those "entitled few" who expect much more that they deserve...that they somehow are "entitled" to be served by us. That abuse of the system needs to stop.....but with blanket statements and reform it hurts our most vulnerable population....the elderly who are fiercely hanging on to whatever dignity they can.

That homeless man? He Lost his job when the market crashed. He's run out of benefits. He has lost his home his life savings his job his dignity......or maybe he is one of those pitiful few that have fallen through the cracks.....not ill enough to be hospitalized or placed in half-way homes but not well enough function and get a job, besides they can't afford the meds any way. But The IV drug abuser gets clean needles and a warm blanket.

I have seen this brutal treatment of individuals at for profit facilities.....both acute care and Long term acute care. You leave when the paid days are gone. Before the new medicare rules about re-admission diagnosis time limit with similar diagnosis....this place had a 36 hour turn around re-admit rate with the discharges to the nursing home/rehab next door becasue once paast 24 hours.....a whole new reimbursement scale started. So....the goal was to get them out ASAP....if they were apporved for a hip fpr 8 days (flat out paid:lump sum) get them out in 5 they are gone for 24 and are redamitted for another approved 8 days and are out in 3 .....that's a net of 8 paid days.

Stop the abuse not the system.

Just take a moment to reflect before you judge......

MN-Nurse, ASN, RN · Apr 26, 2012

Another homeless man 'took him in' at an abandoned construction trailer and the patient stayed there for a couple weeks (without pain meds or antibiotics). At least the other homeless guy shared food and blankets with him.
Does anyone else see this happening in their hospital? Do these patients return when their condition either deteriorates or when they are simply in too much pain or unable to care for themselves?

I have never seen a med surg patient treated like you describe at my hospital. It goes completely the other way. People who are completely stable get admitted and challenge their discharges fairly regularly.

Patti_RN · Apr 26, 2012

Our region is dominated by one major hospital 'non-profit' that sure acts like a for-profit company. They are ruthless with their employees, vendors, and patients (except those with premium insurance).

The homeless in our area don't have feelings of entitlement nor are they demanding. Some do work the system, and some try to get sheltered at hospitals by claiming chest pain. But, for the most part, these are individuals who were not on the fringes of society a decade ago, and don't navigate the system or abuse it. Many were gainfully employed but had a health crisis that began their downward spiral. It's a fairly typical story: Family with one or two incomes and health insurance through the employer... someone in the family becomes sick (usually the person with health insurance), and is off work for months. Their employer terminates them, they lose their income and their health insurance. Money is scarce and they lose their home or apartment. The family moves in with a brother or sister until that relationship turns sour (which doesn't take long with the stress of living with another family with no source of income). They move to another relative's house, and some months later that relationship suffers. When they've exhausted all their relatives' and friends' offers of housing, they move into their car. The kids have changed schools a number of times and are usually failing, if they're going to school, at all. The marriage is suffering, and the patient's health is usually still an issue (which prevents them from getting another job, or health insurance--if they could afford it). There are very few 'family shelters' so the wife and kids move to one, and the sick husband might be living in someone's garage or on the streets.

Most of us see people who are homeless and imagine it is by 'choice' or 'lack of motivation' or 'poor choices'. Of course there are some who fit this description, but most are on the streets because of one significant period of bad luck. Some never get off the street. Some are addicts or alcoholics prior to their homelessness, others become addicts out of hopelessness and opportunity. The ones who are addicted have a worse time getting off the streets. And, if you think it's tough beating an addiction with the help of your employer, your health insurance, and social service programs that are geared to the employed, imagine how difficult it must be to break an addiction without help. And, contrary to what people believe, many street drugs are dirt cheap, keeping the addict from needing to make an economic decision to stop using.

I've seen some 'urban campers'--mostly teenagers and young adults who hang out in places like the Pacific Northwest or southern California. They are different types than the population I deal with. But, even those kids who seem to have made homelessness a choice must have lived very unhappy, marginalized lives to give up on traditional life and creature comforts for a life on the street.

The most frightening part of the problem of homelessness is how close most of us are to being there. We look at the disheveled men shuffling along in stained clothes with scraggly hair, and we think how different they are from us. We swear it wouldn't be us... it couldn't be us... After all, we're educated, we have families, jobs, health insurance and pride. But, add a serious illness to that equation and we might lose the job, then we lose the heath insurance, then we have no money for rent or mortgage... and soon the house of cards tumbles. Read some of the stories on this board of people looking for nursing jobs- it's not easy to find one, even if you're experienced, but probably impossible if you're seriously ill. Denial is such a convenient way of removing ourselves from the frightening thought that with a few doses of bad luck, we could be homeless. We're quick to point out differences between those scraggly men and us... but underneath those filthy clothes and unkempt hair may be a person very similar to you and me... just one who had worse luck.

rubato, ASN, RN · Apr 27, 2012

Patti_RN, thanks for addressing this. It's absolutely horrible the way we treat our homeless. My son is a homeless outreach worker as his career and also works part time at a shelter. He sees such prejudice against these people that are, more times than not, mentally impaired or like you said, just had one time of bad luck. Very sad!

Vespertinas · Apr 27, 2012

Thank you Patti and Esme for reminding me of the flip side. It's easy to get caught up in the negativity.

Patti_RN · Apr 27, 2012

People who work directly with the homeless have hundreds of stories... some funny, some infuriating, but most of them just sad.

I'm not advocating that the homeless (or anyone else) should enjoy benefits beyond what others receive. But, I do think that everyone is entitled to emergency and urgent care, and adaquate follow-up thereafter.

As Esme said, the elderly can no longer drive themselves home, the homeless have no home to go to until they're recovered enough to life that hard life on the streets. We're not granting them a limo or a room at the Ritz Carlton, just a little help so they can eventually get back to the same place they were before their hospital admission.

The elderly patients may no longer pay income taxes; the homeless man probably paid his share along the way. Hospitals get grants and other funding to care for the poor. No one ever said that we get ALL our tax money back in services, or that once we get all our tax money back in services we're automatically cut off from receiving more. Ironically, those who complain the most about subsidizing others are often the ones who receive a disproportionate share of benefits. Most people send their kids to public schools but the elderly still pay taxes to support those schools even though their own children graduated decades ago. Do we complain because our kids are getting free education at the expense of the retired or the childless? It all balances out in the end... or at least close to balances.

And, thanks, Vespertinas for being open minded about a highly charged issue.