Commentary — October 2017
By Michael Stefanowicz, DO
For even the most complex patients with prolonged hospital stays, the hospital discharge can be a hurried ordeal. The rush to finally get a patient out the door frequently makes several assumptions: that the patient has access to family support and a means of transportation for outpatient follow-up appointments, and, perhaps most fundamentally, that the patient will return to the comfort of secure lodging. For many of the patients at Dell Seton Medical Center at The University of Texas, Austin's only safety net hospital, shelter upon discharge is not a guarantee. In fact, a significant number of Austin's most vulnerable homeless men and women rely on the hospital for medical care. One would be hard-pressed to find a physician at the hospital who has not discharged a patient back to the streets knowing that this same person will likely return with the same condition, perhaps in a more advanced presentation.
Leaving the broader conversation on health care costs aside, it is not feasible for any hospital to retain medically stable people for lengthy stays simply because they are homeless. Yet studies have suggested that homeless patients remain hospitalized longer than housed patients who have similar medical conditions. Furthermore, there is a growing movement in America's cities to help homeless men and women find a temporary place to heal while saving health care dollars. Respite care, or recuperative care, is step-down care for homeless men and women who may no longer require acute hospital care yet still need basic medical attention and/or rehabilitation. It is an increasingly popular and potentially cost-effective approach to transitioning medically fragile people from the acute stages of convalescence back to fuller health. One day of respite care costs approximately $700, half the cost for one day of hospitalization.1
Strong evidence suggests that homeless men and women use the emergency department (ED) and acute care services far more than their housed counterparts. Data from Austin ECHO's 2015 report notes that approximately 63% of homeless people used ED services within the prior six months, and 33% were hospitalized.2 While there is no readily available data that tracks the readmission rate of homeless patients in Austin, there is data documenting higher readmission rates and health care overutilization in other U.S. cities. Anecdotally, Dell Seton Medical Center sees a significant number of "bounce-backs" among homeless patients who are discharged to the street.
At a basic level, respite care offers meals, shelter, medication management, and, in some cases, ancillary health care services such as physical therapy while people get back on their feet. Many respite facilities offer some sort of social services that coordinate care. Some programs even focus on obtaining permanent housing. One study of respite care coupled with transition to housing among HIV-positive patients showed a statistically significant increase in CD4 count and decrease in viral load.3
As health care costs rise, it would behoove physicians and health care leaders to realize that health care dollars spent on Travis County's most vulnerable people are inextricably linked to lack of affordable housing. Early data yielded from medical respites for the homeless has shown that not only is it cost-effective but that it also affords those often frail human beings in the earliest days following an acute illness the opportunity to recover under the auspices of guaranteed shelter, food, and relative comfort. Most would consider these offerings to be absolutely vital to a person's recovery. Thus, any physician who has been forced to discharge a patient back to the streets should be advocating for medical respite programs as a means to ensure a safer and more compassionate transition from the hospital.
Michael Stefanowicz, DO, is a second-year family medicine resident at The University of Texas at Austin Dell Medical School.