Discharging Patients Home When There’s No Home to Go to


As an emergency medicine physician, I care for people experiencing homelessness on every single shift that I work in the emergency department.  Sometimes individuals come to us very sick and other times, the health issues are less urgent.  Less often, people come looking for a place to sleep or a sandwich.  And then there are the patients brought in by ambulance for sleeping in a public place while intoxicated.  All of these types of patients need unique solutions that will only be found when health systems and social systems begin truly collaborating. 

The patients I find most discouraging, though, are those who end up in the emergency department within weeks or even days after having been discharged from the hospital.  These are patients who our health and social welfare systems have truly failed.  Recently, I wrote a Huffington Post blog about what happens when patients are discharged “home” from the hospital without a home to go to.  The take home point is that homeless patients are at high risk for hospital readmissions, which is bad for patients and costly to the health system.   

New Centers for Medicare & Medicaid Services (CMS) regulations penalize hospitals for having excess readmissions among Medicare patients hospitalized for certain diagnoses.  Because most homeless patients do not have Medicare, their hospitalizations are not currently counted toward the penalties.  And here in Connecticut, where homeless adults are covered by Medicaid, hospitals are actually paid every time homeless patients are readmitted – a true example of perverse incentives. 

There are solutions, however.  Medical respite programs have shown promise in reducing hospital readmissions among homeless patients.  In New Haven we are working hard to start such a program, under the leadership of Columbus House, Inc.  Though I enjoy caring for homeless patients in the emergency department, I am looking forward to a day when far fewer are coming to see us after recent hospitalizations!

Kelly Doran, M.D., is an emergency physician and Robert Wood Johnson Foundation Clinical Scholar at the Yale School of Medicine. 

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