san francisco medical respite: defining a successful discharge

San Francisco Medical San Francisco Medical Respite:Respite:

Defining a Successful Defining a Successful DischargeDischarge

Michelle Nance, RN, NP - Midlevel Michelle Nance, RN, NP - Midlevel providerprovider

Michelle Schneidermann, MD - Medical Michelle Schneidermann, MD - Medical DirectorDirector

Shannon Smith, RN,MS,CNL - Intake Shannon Smith, RN,MS,CNL - Intake CoordinatorCoordinator

Alice Y. Wong, RN,CNS - Nurse Alice Y. Wong, RN,CNS - Nurse ManagerManager

ObjectivesObjectives

Briefly describe the San Francisco Medical Briefly describe the San Francisco Medical Respite ProgramRespite Program

Describe measures of success respite Describe measures of success respite programs can use when evaluating dischargesprograms can use when evaluating discharges

Describe the internal and external Describe the internal and external philosophies that influence discharge from philosophies that influence discharge from medical respitemedical respite

Learn to identify and incorporate hospital and Learn to identify and incorporate hospital and community needs into discharge planningcommunity needs into discharge planning

Mission StatementMission Statement

The mission of the Medical Respite Program The mission of the Medical Respite Program is to provide recuperative care, temporary is to provide recuperative care, temporary shelter, and coordination of services for shelter, and coordination of services for medically and psychiatrically complex, medically and psychiatrically complex, homeless adults in San Francisco. homeless adults in San Francisco.

ValuesValues

We believe that: We believe that: Every person has the right to housing, Every person has the right to housing,

health care, and food security.health care, and food security. All people have the right to self-All people have the right to self-

determination.determination. Every person is valued and entitled to Every person is valued and entitled to

dignity and respect. dignity and respect. Homelessness is the result of a complex set Homelessness is the result of a complex set

of circumstances and necessitates a of circumstances and necessitates a multifaceted approach toward resolution.multifaceted approach toward resolution.

A dedicated team can have a positive impact A dedicated team can have a positive impact on the life of individuals and the community. on the life of individuals and the community.

VisionVision

Our vision is to:Our vision is to: Encourage healing and stabilization by providing Encourage healing and stabilization by providing

respite from homelessness;respite from homelessness; Provide individualized assessment of client needs Provide individualized assessment of client needs

and a comprehensive plan of care; and a comprehensive plan of care; Advocate a harm reduction model to decrease the Advocate a harm reduction model to decrease the

negative impact of unsafe behaviors;negative impact of unsafe behaviors; Provide compassionate, nonjudgmental, Provide compassionate, nonjudgmental,

interdisciplinary, and state-of-the-art care;interdisciplinary, and state-of-the-art care; Collaborate with local entities to coordinate Collaborate with local entities to coordinate

provision of care, options for housing, and provision of care, options for housing, and initiation of entitlement process; andinitiation of entitlement process; and

Forge relationships with local, regional and Forge relationships with local, regional and national networks of those who serve homeless national networks of those who serve homeless persons. persons.

The Vulnerable The Vulnerable & Medically & Medically Complex Complex Homeless in SFHomeless in SF

SF Homeless DemographicsSF Homeless DemographicsSan Francisco Homeless San Francisco Homeless

Count 2007Count 2007 Done by SF Human Services Agency, March Done by SF Human Services Agency, March

20072007 African American/Black 47.6%African American/Black 47.6% Caucasian 43.4%Caucasian 43.4% Male 80.2%Male 80.2% Female 19.4%Female 19.4% Transgender 0.3%Transgender 0.3%

Sheltered HomelessSheltered Homeless Transitional Housing and Treatment CentersTransitional Housing and Treatment Centers Resource Centers and StabilizationResource Centers and Stabilization JailJail HospitalHospital Unsheltered countUnsheltered count Total Count: n=6,377Total Count: n=6,377

Health and Health and HomelessnessHomelessness

The average life expectancy of a homeless The average life expectancy of a homeless person is 42-52 yrs (average in US is 80 yrs)person is 42-52 yrs (average in US is 80 yrs)

Homelessness magnifies poor healthHomelessness magnifies poor health Exposes people to communicable illness and traumaExposes people to communicable illness and trauma Complicates management of chronic illnessComplicates management of chronic illness Makes health care harder to accessMakes health care harder to access

Homeless patients are more likely to be seen Homeless patients are more likely to be seen in ED and admitted and have longer LOS than in ED and admitted and have longer LOS than other patients other patients

Salit, S. et al (1998)Salit, S. et al (1998)

The Hospitalized The Hospitalized HomelessHomeless

Treatment plans that make sense for Treatment plans that make sense for housed patients don’t work for homeless housed patients don’t work for homeless patientspatients No bed for bed restNo bed for bed rest Difficult to keep wounds cleanDifficult to keep wounds clean Adherence to meds and appointments suffersAdherence to meds and appointments suffers Impossible to follow diet and exercise Impossible to follow diet and exercise

recommendationsrecommendations Often have no support system to help with Often have no support system to help with

treatment plantreatment plan

Hospitalized Homeless: Hospitalized Homeless: The San Francisco The San Francisco

ExperienceExperience Around 20% - 30% of patients Around 20% - 30% of patients

admitted to San Francisco General admitted to San Francisco General Hospital (SFGH) are homelessHospital (SFGH) are homeless

Most of those patients are Most of those patients are chronically homelesschronically homeless

Safe and effective discharge plans Safe and effective discharge plans are difficult to constructare difficult to construct

What Respite OffersWhat Respite Offers

Successful resolution of acute conditions Successful resolution of acute conditions and stabilization of chronic conditionsand stabilization of chronic conditions

Linkages to additional servicesLinkages to additional services Development of plans focused on Development of plans focused on

positive long-term changespositive long-term changes Recuperation from not only physical Recuperation from not only physical

illness, but also the emotional distress illness, but also the emotional distress and isolation that accompany and isolation that accompany homelessnesshomelessness

Demographics of SF Medical Demographics of SF Medical Respite ProgramRespite Program

Ethnicity (and Ethnicity (and Gender): Reflect Gender): Reflect homeless homeless population of San population of San FranciscoFrancisco

Gender: 80% Gender: 80% male/20% femalemale/20% female

Caucasian45%

Multiple Ethnicity

0%

Filipino/a1%

AI/Alaskan Native

2%

Other2%

Asian/PI2%

Latino/a12%

African American

36%

San Francisco HospitalsSan Francisco Hospitals

The Medical Respite accepts clients from The Medical Respite accepts clients from 10 area hospitals. 10 area hospitals.

San Francisco General Hospital and San Francisco General Hospital and Trauma CenterTrauma Center 300+ bed acute care public hospital including 300+ bed acute care public hospital including

only Level 1 Trauma Center in San Francisco only Level 1 Trauma Center in San Francisco area. area.

Nine other community hospitalsNine other community hospitals Total: 2,200 Hospital BedsTotal: 2,200 Hospital Beds

Referring HospitalsReferring Hospitals

SFGH81%

CPMC California

0%CPMC Pacific Campus

2%Other1%

St. Mary's1%

UCSF5%

CPMC Davies2%

St. Francis2%

VAMC5%

Kaiser0%

St. Luke's1%

Note: Other clients came from outpatient surgery Note: Other clients came from outpatient surgery and DPH case management programsand DPH case management programs

Discharge Venues in San Discharge Venues in San FranciscoFrancisco

Permanent HousingPermanent Housing Direct Access to Housing (DAH)Direct Access to Housing (DAH)

Supported (may include SW, CM, RN)Supported (may include SW, CM, RN) Single Room Occupancies (SRO)Single Room Occupancies (SRO)

Non-supported Non-supported Supported (may include SW, CM, RN) Supported (may include SW, CM, RN)

Apartment/ HouseApartment/ House

Discharge Venues Discharge Venues

Shelter SystemShelter System GA Shelter Bed: 30-90 daysGA Shelter Bed: 30-90 days A Woman’s PlaceA Woman’s Place shelter: up to 6 shelter: up to 6

monthsmonths City shelter: Case management; up City shelter: Case management; up

to 6 monthsto 6 months City shelter: No case management; 1 City shelter: No case management; 1

weekweek

Discharge VenuesDischarge Venues

Higher Level of Care Higher Level of Care Board and CareBoard and Care Long Term Care FacilityLong Term Care Facility Emergency Department/ Inpatient Emergency Department/ Inpatient

ServicesServices Residential TreatmentResidential Treatment Hospice Hospice

Discharge in the Discharge in the LiteratureLiterature

Zerger, S (2006): Discharge Zerger, S (2006): Discharge standard of practice is that a client’s standard of practice is that a client’s primary admitting diagnosis has primary admitting diagnosis has been stabilized prior to discharge been stabilized prior to discharge

RCPN practice models state a safe RCPN practice models state a safe discharge from respite care entails discharge from respite care entails follow-up servicesfollow-up services

Program Measures of Success: Program Measures of Success: Short TermShort Term

Completion of treatment plan, including Completion of treatment plan, including demonstrated independence with self-demonstrated independence with self-care and medication managementcare and medication management

Improved living situation after discharge Improved living situation after discharge from Respitefrom Respite

Engagement with primary care and Engagement with primary care and specialty carespecialty care

Linkages to social services, benefitsLinkages to social services, benefits Referrals to mental health and Referrals to mental health and

substance abuse servicessubstance abuse services

Medical Treatment Plan Medical Treatment Plan CompletionCompletion

Left or discharged prior to completing

treatment35%

Discharged to a Higher Level of

Care10%

Completed Treatment

55%

Treatment PlanTreatment Plan

Treatment Plan Completed!Treatment Plan Completed!

Length of Stay by Days and Length of Stay by Days and DispositionDisposition

DispositionDisposition Mean Mean (Days)(Days)

Median (Days)Median (Days)

All Respite ClientsAll Respite Clients 4040 2828

AWOLAWOL 1414 55

AMAAMA 1717 1111

Supported SROSupported SRO 7676 7373

Non-supported SRO or Non-supported SRO or ShelterShelter

3232 2121

Completed Treatment Completed Treatment PlanPlan

5555 4747

Did Not Complete Did Not Complete Treatment PlanTreatment Plan

1717 1010

Discharge DispositionDischarge Disposition

Self Care51%

Police Custody2%

Inappropriate behavior

3%

Violent Behavior4%

AMA9%

AWOL18%

ED10%

Long Term Care1%

Hospice0%

Residential Treatment

1%

Medical Detox1%

Linkages Made at Respite: Medical Linkages Made at Respite: Medical ServicesServices

73.7

57.8

9.1

2.6

10.715.2

67.7

52.7

8.6

2.1

9.5 10.7 11.415.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Primar

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e Pro

vider

Specia

lty C

are

Diagn

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s

Inte

grate

d Cas

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agem

ent

Comm

unity

Nur

sing

Care

Men

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ealth

Tre

atm

ent

Substa

nce

Abuse

Tre

atm

ent

Pe

rce

nta

ge

of

Clie

nts

All Clients (n=421)

minus AMA/AWOL (n=308)

Linkages Made at Respite: Linkages Made at Respite: Social ServicesSocial Services

62.7

71.7

32.8

67.2

75.6

23.725.9

23.3

0

10

20

30

40

50

60

70

80

Permanent Housing Identification card Income benefit Medical coveragebenefit

Per

cen

tag

e o

f C

lien

ts

All Clients (n=421)

minus AMA/AWOL(n=308)

Internal and External Internal and External PhilosophiesPhilosophies

External Philosophies: External Philosophies: HospitalHospital

““Enormous amounts of energy are spent Enormous amounts of energy are spent re-stabilizing many of our homeless re-stabilizing many of our homeless clients. Rather than successful long-clients. Rather than successful long-term management we frequently are term management we frequently are only treating acute exacerbations of only treating acute exacerbations of the chronic conditions. Respite has the chronic conditions. Respite has been able to provide stability and been able to provide stability and management to many of our clients.” management to many of our clients.”

- SFGH Attending - SFGH Attending PhysicianPhysician

External Philosophies: External Philosophies: HospitalHospital

““We’d love to see people get into housing, We’d love to see people get into housing, especially the frequent flyers. However, we especially the frequent flyers. However, we want to be able to refer more people and there want to be able to refer more people and there is often a wait for a bed. So we can’t refer to is often a wait for a bed. So we can’t refer to you [Respite] if you do not discharge clients to you [Respite] if you do not discharge clients to shelter, as there are not enough beds.” shelter, as there are not enough beds.”

““The perfect discharge would have them go into The perfect discharge would have them go into some type of housing, an SRO. Transition back some type of housing, an SRO. Transition back into the community in some sort of living into the community in some sort of living situation, rather than back into the streets. But situation, rather than back into the streets. But I know we don’t live in a perfect world.” I know we don’t live in a perfect world.”

-SFGH Discharge Social -SFGH Discharge Social WorkersWorkers

External Philosophies: External Philosophies: CommunityCommunity

““Our homeless clients, in general, use our Our homeless clients, in general, use our ambulances and EDs much more frequently ambulances and EDs much more frequently than the typical housed client. In addition to than the typical housed client. In addition to overburdening the emergency medical overburdening the emergency medical service, this care does not address their long-service, this care does not address their long-term needs. They need access to regular term needs. They need access to regular medical care and medications, stable medical care and medications, stable housing, psychiatric and substance abuse housing, psychiatric and substance abuse services, case management…The ideal services, case management…The ideal scenario would be to establish all of this prior scenario would be to establish all of this prior to their discharge. To give them a solid to their discharge. To give them a solid network of support.”network of support.”

-San Francisco Paramedic -San Francisco Paramedic Captain Captain

External Philosophies: External Philosophies: CommunityCommunity

““We have few expectations of what We have few expectations of what you do for clients because we you do for clients because we assume they don’t have anything. assume they don’t have anything. What we like about Respite is at What we like about Respite is at least their medical linkage is done.”least their medical linkage is done.”

-SF HOT (Homeless Outreach Team) -SF HOT (Homeless Outreach Team) Case ManagerCase Manager

Referral DifficultyReferral Difficulty

Inpatient teams often express the Inpatient teams often express the enormous pressure they are under enormous pressure they are under to discharge their clients.to discharge their clients. ““We need to discharge today” We need to discharge today”

Referral DifficultiesReferral Difficulties

Inappropriate referrals lead to difficult Inappropriate referrals lead to difficult dischargesdischarges

Need higher level of care than indicatedNeed higher level of care than indicated Incontinence, dementia, not competent, not Incontinence, dementia, not competent, not

able to care for ADLsable to care for ADLs No acute medical need but a number of No acute medical need but a number of

co-morbidities needing longer-term co-morbidities needing longer-term managementmanagement What is the end point for discharge?What is the end point for discharge?

Internal PhilosophiesInternal Philosophies

Multidisciplinary staff:Multidisciplinary staff: Nursing, midlevel providers, MDNursing, midlevel providers, MD AdministrationAdministration Social workersSocial workers Paraprofessional staff (medical Paraprofessional staff (medical

assistants, health workers)assistants, health workers) How do we define a “good” How do we define a “good”

discharge? discharge? How do our internal philosophies How do our internal philosophies

match our stated mission?match our stated mission?

What Is a “Good” What Is a “Good” Discharge?Discharge?

““Our biggest discharge issue is the lack of Our biggest discharge issue is the lack of available, affordable quality supportive available, affordable quality supportive housing.”housing.”

– – John Wiskind, LCSWJohn Wiskind, LCSW

““In reviewing “success,” we look at whether In reviewing “success,” we look at whether people are still housed a year later.”people are still housed a year later.”

– – Mark Hamilton, MSWMark Hamilton, MSW

““Individual housing is the gold standard”Individual housing is the gold standard” – – Cindy Lee, RNCindy Lee, RN


““Completing the acute medical need, but Completing the acute medical need, but that’s balanced with the need to more that’s balanced with the need to more permanently offload burden from the permanently offload burden from the emergency services and hospitals.”emergency services and hospitals.”

– – Michelle Nance, NPMichelle Nance, NP

““Completion of acute medical condition Completion of acute medical condition without being readmitted into the hospital.”without being readmitted into the hospital.”

– – Shannon Smith, RNShannon Smith, RN


““A bad discharge is when we have to call A bad discharge is when we have to call the police. A good discharge is when we the police. A good discharge is when we have done all we can do for someone.”have done all we can do for someone.”

– – Jeanne Andaya, MEAJeanne Andaya, MEA

““The acute medical need is done.”The acute medical need is done.” – – Tae-Wol Stanley, NP, Program Tae-Wol Stanley, NP, Program

DirectorDirector

““The medical need is done, they are started The medical need is done, they are started with linkages, and discharged with with linkages, and discharged with reliable follow up”reliable follow up”

– – Alice Wong, RN, Nurse ManagerAlice Wong, RN, Nurse Manager


““A good discharge means that while at respite, a patient A good discharge means that while at respite, a patient has completed his/her treatment plan, engaged in has completed his/her treatment plan, engaged in primary care, learned self-care and medication primary care, learned self-care and medication management skills, and has begun the process of management skills, and has begun the process of transitioning into permanent housing. There are some transitioning into permanent housing. There are some patients too vulnerable to be discharged from respite patients too vulnerable to be discharged from respite back to the shelter system and a successful discharge back to the shelter system and a successful discharge for those patients would include a move from respite for those patients would include a move from respite directly into permanent housing. While in my fantasy directly into permanent housing. While in my fantasy world, all patients would discharge into permanent world, all patients would discharge into permanent housing, the real world of limited resources forces us housing, the real world of limited resources forces us to triage.”to triage.”

-Michelle Schneidermann, Medical -Michelle Schneidermann, Medical DirectorDirector


“ “ At minimum: a resolution of a medical issue in At minimum: a resolution of a medical issue in an environment that is less costly and more an environment that is less costly and more normalized than the hospital. Even a short time normalized than the hospital. Even a short time (10-15 days) of recuperation that can be done at (10-15 days) of recuperation that can be done at Respite rather than inpatient is cost saving. A Respite rather than inpatient is cost saving. A good discharge is when a client leaves better good discharge is when a client leaves better equipped to find a next phase of a residential equipped to find a next phase of a residential setting. I’d like to see direct uninterrupted setting. I’d like to see direct uninterrupted access to a bed in the system, whether shelter, access to a bed in the system, whether shelter, treatment, stabilization or permanent housing.”treatment, stabilization or permanent housing.”

-- Mark Trotz, Director, Dept of Housing and Urban Mark Trotz, Director, Dept of Housing and Urban HealthHealth

Internal PhilosophiesInternal Philosophies

Staff have different philosophies Staff have different philosophies shaping their discharge decisionsshaping their discharge decisions Can lead to confusion and conflict for Can lead to confusion and conflict for

both staff and clientsboth staff and clients Of note: no clients were asked for a Of note: no clients were asked for a

definition of a successful discharge definition of a successful discharge for this presentationfor this presentation

Who Gets Prioritized for Who Gets Prioritized for Housing?Housing?

OlderOlder In our population, 50 years old is In our population, 50 years old is oldold

Medically frailMedically frail COPD requiring oxygenCOPD requiring oxygen HemodialysisHemodialysis Terminal or severe cancer diagnosisTerminal or severe cancer diagnosis Amputation, paralysisAmputation, paralysis ““Tired”Tired”

Done with the “player” lifestyleDone with the “player” lifestyle Willing to engageWilling to engage

Most unstable/disruptive to systemMost unstable/disruptive to system Heavy Emergency Services useHeavy Emergency Services use

Pre-Hospital Living Pre-Hospital Living SituationSituation

Homeless Transitional

10%

Permanently Housed

7%

Homeless83%

Living Situation at Respite Living Situation at Respite DischargeDischarge

Homeless Transitional15%

Permanently Housed28%

Homeless57%

Living SituationLiving Situation

51% of clients had a change in living 51% of clients had a change in living situation for the bettersituation for the better

44% of clients had no change in 44% of clients had no change in living situationliving situation

Is Individual Housing the Gold Is Individual Housing the Gold

Standard of a Discharge?Standard of a Discharge? ““What a lot of clients need is a mom and that’s What a lot of clients need is a mom and that’s

what they get at Respite: nagging, what they get at Respite: nagging, reminders, family and friends, increased reminders, family and friends, increased social interactions, meals. They lose this in social interactions, meals. They lose this in housing.” housing.”

– – Cindy Lee, RNCindy Lee, RN

““We tend to think of housing as the gold We tend to think of housing as the gold standard, but for many clients having an standard, but for many clients having an individual room doesn’t work – they individual room doesn’t work – they decompensate in that situation.” decompensate in that situation.”

– – John Wiskind, LCSWJohn Wiskind, LCSW

Is Housing the Gold Is Housing the Gold Standard?Standard?

Supportive Housing (SH) programs Supportive Housing (SH) programs become less willing to take our clients become less willing to take our clients because the clients are too because the clients are too sick/disorganizedsick/disorganized

SH asked to be “hospice lite;” staff SH asked to be “hospice lite;” staff gets overburdened and burned outgets overburdened and burned out

Should we prioritize “less sick” Should we prioritize “less sick” clients for SH instead of the most clients for SH instead of the most fragile so there’s more success?fragile so there’s more success?

Are there other options?Are there other options?

Next Steps?Next Steps? Creating more communal living situationsCreating more communal living situations

Smaller group homes with support servicesSmaller group homes with support services Encouraging community in SROsEncouraging community in SROs

Foster creation of Medical Rest Beds in SheltersFoster creation of Medical Rest Beds in Shelters For clients who are awaiting housingFor clients who are awaiting housing Communal livingCommunal living Medical/social supportMedical/social support Free up Respite beds for acute needsFree up Respite beds for acute needs

Get more dataGet more data Who do we really house?Who do we really house? Outcomes for housedOutcomes for housed

Objective: 911 calls, hospital readmits, evictionsObjective: 911 calls, hospital readmits, evictions Subjective: client’s perceived mood, substance useSubjective: client’s perceived mood, substance use

Next Steps?Next Steps?

Re-examine our internal philosophies Re-examine our internal philosophies on dischargeon discharge

Create more objective measures for Create more objective measures for who we hold for housingwho we hold for housing Assessment toolAssessment tool ““transplant waitlist”transplant waitlist”

Formalize team discussions of Formalize team discussions of referralsreferrals e.g., a “tumor board” for housinge.g., a “tumor board” for housing

Respite Alumni NetworkRespite Alumni Network

Incorporating These Incorporating These Philosophies into Discharge Philosophies into Discharge

PlanningPlanning Identifying when housing IS the gold Identifying when housing IS the gold

standard and appropriatestandard and appropriate Ex: Client is medically complex and ready to Ex: Client is medically complex and ready to

engageengage Triaging and creating individualized Triaging and creating individualized

discharge plans based on medical and discharge plans based on medical and psycho-social need and willingness to psycho-social need and willingness to engageengage

Education and understanding that Education and understanding that sometimes a successful discharge does not sometimes a successful discharge does not include a direct, uninterrupted discharge to include a direct, uninterrupted discharge to housinghousing

Case StudiesCase Studies

Mr. BMr. B 66 year-old man with a long history of 66 year-old man with a long history of

asthma, COPD, asbestos exposure, tobacco asthma, COPD, asbestos exposure, tobacco and alcohol abuse, and depression, who and alcohol abuse, and depression, who was admitted to the hospital for was admitted to the hospital for pneumonia.pneumonia.

X-ray and CT scan of the chest showed X-ray and CT scan of the chest showed large masses in his lungslarge masses in his lungs

Confirmed to be extensive small cell lung Confirmed to be extensive small cell lung cancercancer

Started on chemotherapy and transferred Started on chemotherapy and transferred to Medical Respite 6 days later…to Medical Respite 6 days later…

Mr. B: At RespiteMr. B: At Respite

Admitted on January 31, 2008 for Admitted on January 31, 2008 for assistance with follow-up assistance with follow-up chemotherapy treatment and chemotherapy treatment and appointmentsappointments

Stayed at Respite for 78 days until Stayed at Respite for 78 days until discharge into Supportive Housingdischarge into Supportive Housing

Stopped drinkingStopped drinking Reconnected with his daughters in OKReconnected with his daughters in OK

Mr. B: After RespiteMr. B: After Respite Came back to visit and showed us pictures of Came back to visit and showed us pictures of

his granddaughters after a visit to see his family his granddaughters after a visit to see his family in OKin OK

Had last day of chemo and decided to celebrateHad last day of chemo and decided to celebrate Relapsed for 9 days when his case manager Relapsed for 9 days when his case manager

finally found himfinally found him Was admitted to a detox facilityWas admitted to a detox facility Returned to supportive housingReturned to supportive housing January 2009: entered hospice careJanuary 2009: entered hospice care March 2009: Mr. B died in hospiceMarch 2009: Mr. B died in hospice

Mr. M Mr. M 33 year-old man with a history of poorly 33 year-old man with a history of poorly

controlled diabetes, polysubstance abuse, controlled diabetes, polysubstance abuse, depression, post-traumatic stress disorder, depression, post-traumatic stress disorder, schizoid personality disorder, admitted to the schizoid personality disorder, admitted to the hospital for DKA.hospital for DKA.

Immigrant from DRCImmigrant from DRC History of being boy soldier, imprisonment, History of being boy soldier, imprisonment,

and tortureand torture Poor adherence to insulin regimenPoor adherence to insulin regimen Admitted to Respite for stabilization of blood Admitted to Respite for stabilization of blood

glucose levels while awaiting follow-up glucose levels while awaiting follow-up appointment with primary care providerappointment with primary care provider

Mr. M: At RespiteMr. M: At Respite ChallengesChallenges

Cultural IssuesCultural Issues Complex psychiatric historyComplex psychiatric history Brittle diabeticBrittle diabetic

Behavior at RespiteBehavior at Respite Compliant with medication regimen and Compliant with medication regimen and

medical needsmedical needs Patient split between professional and Patient split between professional and

paraprofessional staffparaprofessional staff Threatened to kill a Respite WorkerThreatened to kill a Respite Worker

What Would You Do?What Would You Do?

What We DidWhat We Did

No tolerance policy for violenceNo tolerance policy for violence Partnered with patient’s pre-existing Partnered with patient’s pre-existing

case managercase manager Behavioral contract until case manager Behavioral contract until case manager

could find alternative placecould find alternative place Capitalized on respect for clinical staff Capitalized on respect for clinical staff

to continue managing his medical needto continue managing his medical need Case manager was able to secure a 28-Case manager was able to secure a 28-

day stabilization room 24 hours laterday stabilization room 24 hours later

Mr. CMr. C 52 year old man with history of CHF, CAD, CVA with 52 year old man with history of CHF, CAD, CVA with

L hemiparesis and slurred speech; w/c bound; L hemiparesis and slurred speech; w/c bound; hidradentitis suppurativa; microcytic anemia; HTN; hidradentitis suppurativa; microcytic anemia; HTN; Hep B; Hep C. 35 pack-year tobacco history; denies Hep B; Hep C. 35 pack-year tobacco history; denies ETOH or SA ETOH or SA

Left buttock wound with fistulaLeft buttock wound with fistula Staying in shelters and had been unable to do wound Staying in shelters and had been unable to do wound

care on own so presented to the Wound Care Clinic.care on own so presented to the Wound Care Clinic. Was hospitalized for a left buttock abscess and fistulaWas hospitalized for a left buttock abscess and fistula Referred to Respite for ongoing wound care of the Referred to Respite for ongoing wound care of the

perirectal area and bilateral buttock and to f/u with perirectal area and bilateral buttock and to f/u with PCP for his microcytic anemia. PCP for his microcytic anemia.

Also needed IHSS worker Also needed IHSS worker

Mr. C: At RespiteMr. C: At Respite Respite cannot offer a hospital bedRespite cannot offer a hospital bed Was not independent with bathing: required two-Was not independent with bathing: required two-

person assist with bathing and wound careperson assist with bathing and wound care Not always compliant with wound care and Not always compliant with wound care and

hygiene recommendationshygiene recommendations Lost Section 8 housing and wait list was long for Lost Section 8 housing and wait list was long for

ADA roomADA room IHSS worker would be helpful, but needed IHSS worker would be helpful, but needed

housing firsthousing first Wound began to worsenWound began to worsen Was found with frank blood soaked through Was found with frank blood soaked through

clothes and sheets on bed from the woundsclothes and sheets on bed from the wounds

At Respite: Mr. CAt Respite: Mr. C Engaged with Mr. C’s primary care providerEngaged with Mr. C’s primary care provider Wound was to extent it needed surgical repairWound was to extent it needed surgical repair Even if Mr. C went to housing with IHSS, an Even if Mr. C went to housing with IHSS, an

IHSS worker could not offer the kind of care the IHSS worker could not offer the kind of care the wound neededwound needed

Issues: Issues: To high level of care for RespiteTo high level of care for Respite With the PCP we decided to dischargeWith the PCP we decided to discharge

pt’s choice - shelter or hospital for FTTpt’s choice - shelter or hospital for FTT Agreed to admit to SFGH for FTTAgreed to admit to SFGH for FTT Respite Case Manager recently saw him at SFGH Respite Case Manager recently saw him at SFGH

walking in the halls with a walker!walking in the halls with a walker!

Mr. AMr. A

62 year old male s/p R hip fracture, 62 year old male s/p R hip fracture, hx of ETOHhx of ETOH

Admitted first to Respite and went Admitted first to Respite and went AWOL the same dayAWOL the same day

After 48 hours a hospital search After 48 hours a hospital search found he had fallen while acutely found he had fallen while acutely intoxicated and refractured his hipintoxicated and refractured his hip

Readmitted to Respite 1 week laterReadmitted to Respite 1 week later

Mr. A: At RespiteMr. A: At Respite

Engaged with FSA Case ManagerEngaged with FSA Case Manager Decreased ETOH intakeDecreased ETOH intake Gained weightGained weight Expressed desire for treatment Expressed desire for treatment

programprogram Respite challenge: 290 status (sex Respite challenge: 290 status (sex

offender)offender)

Mr. A: At RespiteMr. A: At Respite

Realities of 290 status in San Realities of 290 status in San FranciscoFrancisco

No inpatient treatment program in SF No inpatient treatment program in SF takes 290 statustakes 290 status

Shelters discharge someone with 290 Shelters discharge someone with 290 statusstatus

No inpatient treatment program in No inpatient treatment program in Alameda County will take 290 status, Alameda County will take 290 status, eithereither

Mr. AMr. A

Medical Treatment Plan completedMedical Treatment Plan completed Engaged with primary care provider Engaged with primary care provider

who he sees when he doseswho he sees when he doses Went to stabilization room through Went to stabilization room through

FSA case managerFSA case manager Detox and ETOH treatment plan left Detox and ETOH treatment plan left

to primary care providerto primary care provider

Ms. LMs. L

84 year old female with history of 84 year old female with history of HTN, Afib, anemia, and CHFHTN, Afib, anemia, and CHF

This was her only hospital admission This was her only hospital admission on record at SFGHon record at SFGH

Admitted to Respite to finish Admitted to Respite to finish antibiotics for BLE cellulitisantibiotics for BLE cellulitis

No family involvement. Her only No family involvement. Her only child and only sister have both died.child and only sister have both died.

Ms. L: At RespiteMs. L: At Respite Finished antibioticsFinished antibiotics Received wound careReceived wound care Engaged in primary care through Bridge ClinicEngaged in primary care through Bridge Clinic Through ongoing primary care she became Through ongoing primary care she became

more medically complex and unable to self-more medically complex and unable to self-manage her medicationsmanage her medications

Accepted into supported senior housing in Accepted into supported senior housing in brand-new buildingbrand-new building

Ms. L refused this housing stating, “it’s too Ms. L refused this housing stating, “it’s too new.”new.”

Found competent and not conservableFound competent and not conservable

Ms. LMs. L

Had 122-day length of stayHad 122-day length of stay Bridged primary care to Curry Senior Bridged primary care to Curry Senior

Center that provides case management Center that provides case management to low income seniorsto low income seniors

Discharged to shelter with case Discharged to shelter with case management through Curry Senior management through Curry Senior CenterCenter

Respite received sad news: Ms. L died Respite received sad news: Ms. L died at St. Francis Hospital on May 1, 2009at St. Francis Hospital on May 1, 2009

So: What Is the Definition So: What Is the Definition of a Successful Discharge?of a Successful Discharge?

No single definition of a good dischargeNo single definition of a good discharge We have identified two different We have identified two different

conceptions of a good dischargeconceptions of a good discharge Client discharges to a specific placeClient discharges to a specific place Client has received services and links to Client has received services and links to

services during stayservices during stay In your community you have to balance In your community you have to balance

your external and internal philosophiesyour external and internal philosophies

Thank YouThank You

Questions?Questions?

san francisco medical respite: defining a successful discharge

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