The Pandemic Paused Efforts to Provide Post-Hospital Care for the Homeless

Charles Paul is used to the routine. Over the last year, the 68-year-old homeless San Diegan with heart failure and other health conditions said he has been discharged from local hospitals multiple times with the offer of a bus fare rather than a connection to shelter and a safe place to recover.

That’s also what happened in October, the veteran and cancer survivor said, after an assault in Pacific Beach left him with stitches and staples in his head. Paul said he was given a ride back to Pacific Beach, where he had been living on the street.

A state law that went into effect in 2019 required hospitals to establish plans for discharging homeless patients and to get a handle on resources that might keep them from returning to the street – resources Paul said he would have liked to receive – but the state Department of Public Health last year waived enforcement of its requirements to provide nonmedical services such as weather-appropriate clothing and post-discharge meals as coronavirus patients packed hospitals statewide, and to document details associated with discharges.

San Diego’s major hospital systems, including two that have treated Paul, say they have continued to follow the law’s requirements. For privacy reasons, the two hospitals that released Paul – Scripps Health and UC San Diego Health – say they cannot directly comment on what happened upon his discharge. But Scripps, which discharged him after the October attack, said it offers shelter and transportation to “anyone who needs them prior to their being discharged” and that patients have a right to choose where they want to go after the leave the hospital. UCSD said its discharging homeless patients “are, at a minimum, provided with a list of shelters” and transportation to get there if needed.

“They give you a bus pass and they tell you you’re on your own,” Paul said.

Miguel Angel Chavez, 48, said he had a similar experience early last week after he was discharged following treatment for coronavirus. Chavez, who has diabetes and high blood pressure, said hospital workers didn’t mention shelters or provide a list of options. Instead, Chavez said he simply got a free ride back to East Village, where he lives on the street.

“They didn’t even offer me nothing. I was like, really hurt,” said Chavez, who as of Friday remained on a shelter waiting list that he got himself on.

Stories like Chavez’s and Paul’s highlight both the continued confusion surrounding discharges of homeless San Diegans and the persistence of the gap in post-discharge options for patients who have continuing health issues or underlying conditions and lack a safe place to isolate. Conversations that ramped up in 2019 about how the region might deliver more safe recovery options for homeless patients largely halted as the county pivoted to address the pandemic – and in some cases, shelter options have been dialed back as service providers reduce their capacities to allow for social distancing.

Now regional leaders are promising to restart some of the discussions that dropped off last year amid the chaos of the pandemic.

Still, as the pandemic has dragged on, the flow of homeless patients into local emergency rooms has continued – and at least some homeless San Diegans have been forced back onto the street.

Just how often homeless San Diegans are discharged from hospitals without the prospect of shelter is unclear. What is clear is the confusion surrounding those discharges. Homeless patients can be successfully linked with resources or dropped off at shelters that are unable to accommodate them, as happened to a homeless veteran who was left laying outside the Convention Center last spring after a hospital paid for his cab ride there. Homeless patients can also struggle to advocate for themselves as they prepare to leave the hospital, unsure how to navigate resources they may only learn of from a sheet of paper handed to them. In other cases, hospital spokespeople and advocates say, homeless San Diegans decline shelter offers that don’t seem workable for their circumstances (if they are concerned about being in a bustling shelter during the pandemic, for example) or even try to avoid revealing they are homeless for fear of being treated differently.

What is also clear is that many homeless San Diegans re-emerge on the street after they leave local hospitals, still wearing hospital wristbands and appearing disoriented.

♦♦♦

Before the pandemic, regional and health care leaders were grappling with where the thousands of homeless patients who cycle through local hospitals each year could recover after being discharged.

In 2018, then-City Councilman Chris Ward and then-county supervisor candidate Nathan Fletcher, who now chairs the Board of Supervisors, spotlighted the need for more facilities to provide homeless San Diegans with temporary housing and care. Then, as local leaders assessed the impact of the new state law in 2019, homeless-serving nonprofits Family Health Centers of San Diego, PATH, Salvation Army and Father Joe’s Villages explored whether they could provide that care.

In fall 2019, the city’s homelessness plan urged local officials to add 100 to 150 recuperative care beds equipped to temporarily house homeless people while they recover and to connect them with resources, including longer-term housing.

Service providers thought a state Medi-Cal reform proposal known as CalAIM, which is expected to make recuperative care a reimbursable service, could help fund respite facilities. It had been scheduled to be implemented in January 2021.

But the pandemic disrupted operations at hospitals and homeless shelters and led state officials to postpone Medi-Cal reform plans until 2022.

The rush of coronavirus patients in hospitals statewide also led the state Department of Public Health to last June temporarily waive parts of SB 1152, a decision the department said was appropriate to ensure capacity to serve the sickest patients and avoid unnecessary delays in discharges. The agency also said the waiver was appropriate because “additional support was available to homeless patients” in the form of a burst of state aid that supported the opening of the Convention Center shelter.

In response to questions from Voice of San Diego, the state Department of Health wrote that it expects hospitals to maintain policies and procedures to inquire about patients’ housing status and identify a post-discharge location for homeless patients with priority given to shelter options with supportive services, among other requirements.

“We would still expect the hospital to perform normal discharge activities to ensure that the patient is discharged to an appropriate setting based on care needs,” the agency wrote.

Spokespeople for UCSD , Palomar Health, Scripps and Sharp HealthCare told VOSD they have all continued to comply with the state law throughout the pandemic, though a Scripps spokesman said there have been fewer shelter options available as providers take social distancing precautions.

The recuperative care resources that regional and hospital leaders agreed were needed to help address gaps that existed before the pandemic largely haven’t materialized.

City spokeswoman Ashley Bailey said city and Housing Commission discussions with providers about adding more post-hospital resources were put on pause because of the pandemic.

Father Joe’s Villages and Interfaith Community Services, which already has the largest recuperative care program in the region, report that they have made some headway.

Dr. Jeffrey Norris, Father Joe’s chief medical officer, told VOSD the nonprofit has worked with an unidentified health plan to fund two recuperative care beds and that the agency hopes to add another two soon. The nonprofit hopes to build the program up to as many as 28 beds though Norris acknowledged the pandemic has complicated the process.

In Escondido, Interfaith Community Services plans to expand its recuperative care program later this year.

Some of the regional conversations that began a couple years ago are also poised to start again.

Regional Task Force CEO Tamera Kohler said community leaders coordinating the countywide response to homelessness aim to settle on how to better address the needs of homeless San Diegans leaving local hospitals.

Last month, the task force board voted to create an ad-hoc committee to identify funding for recuperative care, educate hospital workers on interventions to better aid homeless San Diegans they are discharging them and share best practices on how homeless providers and hospitals can collaborate.

“The importance of talking about it is past,” Kohler said. “The importance of actually driving to action is where we’re at with the committee.”

Indeed, while regional conversations about recuperative care and hospital discharge plans grinded to a halt over the last year, concerns about the vulnerability of homeless San Diegans only escalated.  Coronavirus shed more light on the disparities – and the lack of available shelter resources. Coronavirus hasn’t hit the region’s homeless population as hard as some feared, but county data through last Tuesday shows 20.6 percent of confirmed COVID-19 cases in the homeless population required hospitalization compared with just 5 percent for the broader population during the same period.

Experts have long emphasized the medical challenges facing homeless people whose health conditions can fester and escalate on the street, leading to a greater risk of hospitalization and death at a younger age.

Julia Dobbins of the National Health Care for the Homeless Council, who visited San Diego in 2019 to talk to regional officials about recuperative care, said she believes state Medi-Cal reform could bolster efforts to address San Diego’s dearth of post-hospital resources if the finalized plans include support for those services.

For now, Dobbins said, there isn’t a primary funding source for recuperative care programs and providers often struggle to cobble together resources to support them.

“Having recuperative care in that language would make it an optional benefit that could be a reimbursable service for Medi-Cal patients and that would be a huge step forward for respite in the state of California,” Dobbins said.

Fletcher has also said the city and county may be able to use a $25 million behavioral health impact fund created last year to support new resources.

Homeless service providers tell VOSD they haven’t seen an increased demand for post-hospital care during the pandemic, but nonprofit and hospital officials said the need hasn’t decreased.

Sharp spokesman John Cihomsky wrote in an email to VOSD that homeless patients often spend one to three-and-a-half more days in the hospital on average than patients with homes while hospital staff consider their options.

And Palomar Health reports that it’s common for five to 10 homeless patients to be waiting in one of its North County hospital beds for a suitable landing place to become available on any given day.

Advocates have called for the county and city to move homeless people with underlying conditions into hotel rooms to shield them from both the pandemic and the elements.

A UC San Diego Health spokeswoman also suggested the county might consider whether it could use some of its hotel rooms to accommodate homeless San Diegans leaving local hospitals who might recover more easily if they had a safe place to stay.

“It would be very helpful if the current COVID-19 isolation housing, operated by the county, could be transitioned or expanded to include recuperative care for patients whose needs could ordinarily be met in the home setting,” UCSD Health spokeswoman Jacqueline Carr wrote in an email to VOSD.

County spokesman Craig Sturak said the county increased its hotel capacity for at-risk homeless San Diegans in early January in anticipation of increasing case numbers after the holidays, a move that followed weeks of demands by advocates that only grew after an outbreak at the Convention Center shelter.

Sturak did not respond to VOSD’s questions about county progress on discussions about expanded recuperative care services or comments by UCSD or Scripps about how the program could better accommodate homeless patients. Scripps had noted that many of its patients have been unable to qualify for the county’s hotel program.

As of Feb. 17, the county reported it had filled 545 of the 640 rooms it had available to temporarily house homeless San Diegans considered particularly vulnerable to coronavirus. At the same time, 226 of the 312 rooms the county had available for people who had been exposed to coronavirus or tested positive remained unfilled.

Paul is now on a waiting list for a county-funded room after activist Amie Zamudio contacted the county on his behalf more than a month ago. Zamudio began paying for Paul to stay at a hotel herself in late January after seeing him walking Pacific Beach, still wearing a UCSD wristband after breathing issues brought him to the emergency room again.

Spokespeople for UCSD, which has treated Paul most recently, and Scripps Memorial in La Jolla, where Paul said he was taken by ambulance on Oct. 13, wrote in separate statements that they could not comment on Paul’s case for privacy reasons but said they work with each discharging homeless patient to ensure they are given a meal, medication and clothing, as well as transportation and information about resources if they need them.

“We’re proud of the tireless efforts by our dedicated staff in helping patients address what can be very challenging situations in the hospital discharge process,” Scripps wrote in its statement.