Meet the challenge of discharging patients with no way to pay
It takes creativity to meet post-hospital needs
Executive Summary
Case managers and social workers have to look for creative solutions as hospitals struggle with finding a safe discharge for uninsured, undocumented, and homeless patients.
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It's often more cost-effective for hospitals to pay for post-discharge care rather than keeping unfunded patients as inpatients after they no longer meet acute care criteria.
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Undocumented patients sometimes want to go back to their home country for post-discharge care, but many have families in this country who are willing to care for them.
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Some homeless patients have families who are looking for them, but some have been on the street for many years and want to be discharged to the only living situation they know.
Unfunded patients, whether they are homeless, undocumented, or just uninsured, often have tremendous barriers to a safe discharge, particularly if they need post-discharge services.
Finding post-discharge services for patients who no longer meet inpatient criteria but don't have funding for the services they need is a challenge that every hospital in the country struggles with every day, says Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare with headquarters in Norfolk, VA.
"We have to look for innovative solutions. Unfunded patients very often need healthcare services after discharge. This is a very challenging situation because there are times that no facility will welcome an unfunded patient," she says.
When patients no longer need acute inpatient care, keeping them in the hospital is not the best answer for the patient or the hospital, Gonzalvo says. It's often more cost-efficient for the hospital to pay for a lower level of care, and it frees up beds for patients who do need inpatient care and who can pay, she adds. "Additionally, it is more beneficial for patients to receive the discharge services they need," she says. (For a look at how Sentara Healthcare has partnered with post-acute providers, see related article on page 51.)
Unfunded patients, whether they are homeless, uninsured, or undocumented, present unique challenges when it comes to lining up post-discharge services, points out William Gross, LCSW, manager of social work for Tampa General Hospital.
"We treat each patient the same and assess every patient at Tampa General to determine potential barriers to discharge, but we spend a lot more time with patients who don't have a funding source," he adds.
Case managers at Tampa General can tap into the hospital's SWAT (Safe Ways for Alternative Treatment) fund to pay for post-discharge care for patients who would otherwise have to stay in the hospital. (For details on the fund and how it is used, see page 43.)
Challenging patients run the gamut in metropolitan Dallas, adds Pat Wilson, RN, BSN, MBA, case management director at Medical City Dallas Hospital.
"Undocumented patients are a major issue in Texas. In addition, we have one of the highest numbers of uninsured patients in the United States, and like every city, we have a homeless population. Each of these populations have their own issues and their own challenges, and there's no one-size-fits-all solution," she says. At Medical City Dallas Hospital, patients with complex discharge needs are assigned a dedicated social worker who follows them throughout the hospital stay, and starts to identify discharge needs shortly after admission. (For details, see related article on page 46.)
Undocumented patients may have a job and a home and family support but are living under the radar and are unable to apply for insurance benefits. Many organizations that provide assistance to indigent patients are prohibited from providing services to undocumented patients, often eliminating a lot of community resources, Gross says. Some undocumented patients have family in their native countries who can care for them and want to go back after discharge, but many want to stay in this country, he adds.
Many patients who are undocumented have family members who are willing to care for them after discharge, says Helen Hernandez, LMSW, assistant director of social work/discharge planning specialist at Lutheran Healthcare in Brooklyn, NY. As trauma patients become stable, the nursing staff and rehab team work with the family to help them learn to take care of the patient's needs at home.
Many homeless patients have a basic mistrust of society, and it takes time to build trust, Hernandez adds. "We treat them with respect and that helps us involve them in the treatment plan," she says.
Lutheran Medical Center is a Level 1 trauma center, which means a lot of patients come in with major injuries or heart attacks and have no identification. Some are unconscious. Others have mental problems and can't remember their names.
"Some appear to be homeless because they are dirty and unkempt, but many times someone is looking for them. We've had a lot of success in reuniting our patients with their family members," Hernandez says. (For details on how the social workers track down the families and potential funding sources, see related article on page 45.)
Many homeless patients resist being discharged to a homeless shelter because they say it's not safe, Wilson says. "If they are competent, we may discharge them back to the streets. It's not necessarily a bad thing. They are accustomed to living on the street and that environment is what they know and where they feel comfortable," she says.
It's more of a challenge when a homeless patient has medical issues that require post-discharge treatment, Wilson says. Some homeless shelters accept patients with medical issues, but the waiting lists are often long and some patients simply refuse to go. In those cases, the hospital may keep them a little longer. For instance, if a patient needs wound care, the hospital may extend the care for a week and discharge them with a supply of gauze and tape.
Tampa General Hospital occasionally places homeless patients in a skilled nursing facility or assisted living facility with home health services until they are stable enough to go back to the community, Gross adds.
Uninsured patients who either can't afford insurance or simply choose not to purchase it present a different set of challenges, and hospital case managers need to make sure that they are truly indigent, Gonzalvo says.
"Some patients come in as self-pay patients and we find out that they have assets such as savings in the bank or an insurance plan they can cash out. We would prefer for the family and patient to help with the post-acute charges rather than the hospital shouldering the total cost of care. If all else fails, we pay for part of the cost of care," Gonzalvo says.
She recommends that case managers become familiar with all of the resources in the community and partner with agencies that provide discounted medical care and medication, and assistance with psychosocial needs. "There is always something to tap into," she says.
If you are in an area that has a safety net hospital that absorbs the cost of care for indigent patients, help your unfunded patients connect with those facilities, Gonzalvo suggests.
"Most patients don't want to stay in the hospital. When patients are unfunded and need care after discharge, we try to find family members who are willing to take care of them at home and, if necessary, we help out with the resources the patients will need after discharge," Hernandez says.
But keep in mind that patients who are not mentally incapacitated have the right to choose their discharge plan whether you agree with them or not, Wilson adds.
"It doesn't matter if patients are wealthy, uninsured, homeless, or undocumented, case managers have to meet them where they are to help them be successful and for the discharge to be successful," Wilson says.
