Homeless patient with pneumonia

Nurses General Nursing

Published

What resources are available for a homeless patient that is being discharged but he needs further care? He has been in the hospital for the max days allowed for his condition. How would you handle this?

Specializes in Acute Care, Rehab, Palliative.

You mean they are just going to discharge them back to the streets? My hospital would never do that.

Up Vote Up Vote ×
Specializes in Med/Surg, Ortho, ASC.
Actually I am a BSN RN, who works in utilization review and am currently working on my MSN. I thought maybe I could get an idea of community resources in different parts of the country. I am sorry to have troubled the allnurses group.

Unfortunately you chose to pose your question as so many homework-seekers do on a daily basis.

Color us jaded. We are jaded for a good reason. I hope that you receive constructive responses now.

Up Vote Up Vote ×
Actually I am a BSN RN, who works in utilization review and am currently working on my MSN. I thought maybe I could get an idea of community resources in different parts of the country. I am sorry to have troubled the allnurses group.

It sounds that you are talking about a patient who is "medically ready" to get D/C from acute care hospital but is homeless? Different parts of the country is very vague. First of all those cases need the social worker involvement right from the get go. They need to find out if the patient needs a medical shelter or referral to a shelter. It is very complicated because there are restrictions and "dry" shelters and shelters for "user" or not sober people. Different cities have different resources - so your question is way too broad. Some cities and communities offer more than others. It depends on how much is public funding and what other organizations do. It is very specific to the region. Here is an example of services for a large city:

Pine Street Inn | Home

But it gets more complicated. What does aftercare mean? Seeing a PCP? taking medications? Social work can help with that as well. Patients need to be D/C with medications/script and some medical shelters have a service for sick homeless people who get reminded and referred to a clinic for outpatient care.

Once a patient is ready to get D/C and does not appeal, they need to get D/Cd even if they are homeless BUT social work should be involved and ensure that things are in place. For example if a pat gets D/C and needs to stay in a shelter the SW will call the shelter and tell the pat where to show up at which time.

There are dialysis patients who are homeless and do not have a chronic dialysis slot because they have no address or/and behavioral problems/no shows and so on. The go to the ER to get dialyzed unless there is a special arrangement. I worked in one hospital with an acute dialysis room where the patient who is homeless would come to the backdoor, get dialysis and go after that. They set up all kind of accommodations and such but for some patients mental health problems are the main problem all around and the primary reason why they are homeless.

Up Vote Up Vote ×
Specializes in Med Surg, SubAcute, Hospice, Infusion.

I do the entire US as a utilization review RN and do not have personal contact with the patients. Often times we encounter people who are at the end of their treatment and I am trying to compile different resources, possibly come up with some new ideas, for those who need additional care. I guess I am just fishing for new ideas. We have a lot of substance abuse too and like someone said most of these individuals have mental health issues too.

Up Vote Up Vote ×
I do the entire US as a utilization review RN and do not have personal contact with the patients. Often times we encounter people who are at the end of their treatment and I am trying to compile different resources, possibly come up with some new ideas, for those who need additional care. I guess I am just fishing for new ideas. We have a lot of substance abuse too and like someone

said most of these individuals have mental health issues too.

Do you work for an insurance company?

National Coalition for the Homeless The National Coalition for the Homeless - National Coalition for the Homeless

Homelessness Programs and Resources | SAMHSA

if you google medical shelters and a location some information comes up for that area.

If your job is to make sure hospitals D/C patients as soon as medically ready and you want to expedite or make sure they have resources your best bet is to connect with the case managers and social workers on the floor right after admission and touch base with them. All communities have resources and it might be good you create some kind of running list with different organizations in the different locations.

Up Vote Up Vote ×
Specializes in Med Surg, SubAcute, Hospice, Infusion.

I disagree roser13. You say I "chose to pose my question as a homework seeker"....however I simply asked a question. Granted it was a bit vague but I was fishing for ideas and had hoped to garner information from different parts of the US. Your response was harsh and even now has a accusatory tone. You say "color us jaded" but you are speaking for yourself....not for a group. Or at least I hope you are not speaking for a group.

Up Vote Up Vote ×
Specializes in SICU, trauma, neuro.
Actually I am a BSN RN, who works in utilization review and am currently working on my MSN. I thought maybe I could get an idea of community resources in different parts of the country. I am sorry to have troubled the allnurses group.

No trouble...Sometimes nursing students ask questions in a way that is framed as professional conversation, but it's actually homework they haven't bothered to research themselves. I apologize for any incorrect assumption.

To be honest I am not sure how to answer your question... I work for a safety net hospital, and homeless people are kept as long as medically necessary. They are not kept for oral antibiotics when anybody else would be discharged.

Any other community services for this type of thing, should be something the social worker is familiar with, and more in line with the social worker's function.

Up Vote Up Vote ×
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
I disagree roser13. You say I "chose to pose my question as a homework seeker"....however I simply asked a question. Granted it was a bit vague but I was fishing for ideas and had hoped to garner information from different parts of the US. Your response was harsh and even now has a accusatory tone. You say "color us jaded" but you are speaking for yourself....not for a group. Or at least I hope you are not speaking for a group.

Whenever a question is vaguely worded and evokes even a tiny bit of outrage, we smell homework. Roser is certainly welcome to speak on my behalf.

The more information you provide in your initial question, the better we understand what you're looking for. Then you'll get the benefit of everyone's experience.

Up Vote Up Vote ×
Specializes in Med Surg, SubAcute, Hospice, Infusion.

Thank you Nutella!! I appreciate your time and your effort. I will look at these resources and I am sure they will be a great help. Thank you again. Really!

And yes I do work for an insurance company- Sedgwick is the name of the company. I love your idea "create some kind of running list with different organizations in the different locations", which is exactly what I am trying to do. We don't try to DC patients as soon as medically ready, but we do have to follow guidelines, using ODG or other state specific guidelines.

Thanks again for your assistance : )

Up Vote Up Vote ×
Specializes in Med/Surg, Ortho, ASC.
I disagree roser13. You say I "chose to pose my question as a homework seeker"....however I simply asked a question. Granted it was a bit vague but I was fishing for ideas and had hoped to garner information from different parts of the US. Your response was harsh and even now has a accusatory tone. You say "color us jaded" but you are speaking for yourself....not for a group. Or at least I hope you are not speaking for a group.

You literally JUST joined AN.com. You have no context in which to judge your question. I do, and trust me, your initial post presented as a homework seeker. Believe it or not.

However, now that you have given background to your initial post, I have no doubt that you will enjoy the many responses that you will receive.

Up Vote Up Vote ×
Specializes in Critical care.
I disagree roser13. You say I "chose to pose my question as a homework seeker"....however I simply asked a question. Granted it was a bit vague but I was fishing for ideas and had hoped to garner information from different parts of the US. Your response was harsh and even now has a accusatory tone. You say "color us jaded" but you are speaking for yourself....not for a group. Or at least I hope you are not speaking for a group.

I thought it was homework as well. When vague questions are posted like that, especially when the poster has just joined or only has a couple of posts, it tends to be students. We have no problem helping students, but we like to see their work/thoughts. Since you are a new member you weren't aware of this and haven't been around long enough to notice the trend. Roser was not being harsh or accusatory, especially when she said we are jaded- I know I am- she was being matter of fact. AN is a wonderful place to come for information, but sometimes posts need clarification before you really get the responses you wanted.

Now for your original question:

My hospital identifies high risk patients as target patients. We have a complex case management team that is just as it sounds- tackles the hard to place patients. We also try to work with the main mission in the city my facility is in. For patients that aren't necessarily homeless, but are medically noncompliant and/or medical refugees there is a special group of doctors, CMs, and nurses, that work with certain primary care offices to try to keep the patient on track. I can't say for certain what they do, since their interaction is outpatient but I have had them come and visit patients in the hospital to check in. They've also tried to get certain frequent fliers to accept their help so we can try to reduce the number of times they are admitted. Overall I think my organization does a good job. We're the big healthcare provider in my smaller city and the nonprofit one.

I defer to case management a lot, so I might not have explained everything very well. I just don't have the time to handle this stuff. Nurses in my facility are allowed to put orders in for a case management alert as a nursing referral. If I think there are barriers to discharge that haven't been addressed I'll put in an alert. I did just that for an extremely confused elderly pt that came in from home with an elderly spouse- I put in a CM alert regarding placement in a SNF/ECF. Another thing my facility does is as part of our admission assessment with patients we ask if there are any financial concerns- can't afford rent, can't afford food and/or meds, inadequate or no insurance coverage, etc. and then we are automatically prompted to put in a CM alert.

Up Vote Up Vote ×
Thank you Nutella!! I appreciate your time and your effort. I will look at these resources and I am sure they will be a great help. Thank you again. Really!

And yes I do work for an insurance company- Sedgwick is the name of the company. I love your idea "create some kind of running list with different organizations in the different locations", which is exactly what I am trying to do. We don't try to DC patients as soon as medically ready, but we do have to follow guidelines, using ODG or other state specific guidelines.

Thanks again for your assistance : )

You might be interested in reading this - good information and "lingo" to get more into the topic and info about medical respite services for homeless

http://www.nhchc.org/wp-content/uploads/2011/09/FINALRespiteMonograph1.pdf

here an example for a shelter directory

New York Homeless Shelters and Services - New York NY Homeless Shelters - New York New York Homeless Shelters

and

Homelessness and Housing | SAMHSA

What I have noticed is that the toughest placement or general problems are the patients who are homeless and are not sober (alcohol or drugs) as their options are limited. And the one who have mental illness and often untreated are also difficult to connect.

It can be very frustrating because a lot of those patients end up in the ER with re-admissions or refuse to leave the hospital or get "chest pain" when the MD tries to discharge them...

I had followed a patient who was in the 40, homeless, some mental illness and also narcotic user but on dialysis. Continued to come back in because got discharged from all dialysis places. In the end, that person was found dead outside the wet shelter due to complications with infections.

Or the person who has cancer and very smart but mental illness. Did some couch surfing and we could not find a place to stay to continue radiation treatment due to multiple problems including homeless. The patient had to stay in the hospital to finish radiation and after that it was a huge struggle to find a short term rehab place because no health care proxy...

A lot of homeless people who get a terminal illness get too sick to stay on the street or shelter and the state hospital becomes their home - where they get all their care and have access to social work.

If somebody is an elder you can also contact the local elder services office and see if they can help.

The VA can sometimes help with homeless veterans but they have to go to the office in person and also agree to conditions.

Some cities have community health centers, which usually provide a variety of care and also can connect with social work.

There are also "boarding houses" where a person can get a room.

I worked in the community and have seen it all. If you have pat in different states it is really important to get good connections to the different social workers in the most frequented hospitals as they can help you to figure things out.

Often there are community resources that are not as well known and run by churches or dedicated non profits.

Up Vote Up Vote ×
+ Add a Comment