Despite Need, Care Facilities for Homeless Patients Are Underutilized

When the state detailed plans to allow Medi-Cal insurance to pay for recuperative care for homeless patients with health challenges who need safe places to recover, homeless advocates cheered. 

They envisioned the reform helping more homeless San Diegans access potentially life-changing post-hospital support and supplying funding for respite beds that regional leaders agreed San Diego County needed to scale up. 

The initiative hasn’t achieved what they hoped in its first two years. San Diego County Medi-Cal insurers opted to cover recuperative care, but each handled requests differently. Increased bureaucratic red tape and confusion translated into plummeting referrals and sometimes empty beds at existing recuperative care centers. 

Meanwhile, an untold number of homeless San Diegans who might qualify for the service continue to cycle between local hospitals and harsh conditions on the street that exacerbate their health problems. 

Soon after the state began implementing Medi-Cal insurance reforms in 2022, San Diego’s three leading recuperative care providers reported a 50 percent drop in referrals despite broad agreement that their facilities are crucial refuges for a soaring population of homeless San Diegans with health challenges.  

Respite centers provide homeless residents with temporary housing and, depending on the facility, may also supply onsite nurses, transportation to appointments or help coordinating ongoing medical care. Per state guidelines, Medi-Cal patients without stable housing who need a place to heal from an illness or injury and might otherwise end up in the hospital qualify for recuperative care. 

The state’s reforms were meant to increase access for homeless patients, but state data shows just 64 people got into recuperative care facilities in San Diego County in 2022 using their Medi-Cal insurance. The state does not track the number of requests or denials for recuperative care, but the number of placements totals far less than the thousands of homeless patients – many of whom have Medi-Cal insurance – pouring into local hospitals each year. 

There have been improvements since then. In the first six months of 2023, the most recent state data available shows 80 people accessed recuperative care via their Medi-Cal plans – more than the total for all of 2022. 

Challenges remain. Hospitals still often struggle to get their homeless patients in. Hospital social workers must work through convoluted, often days-long Medi-Cal approval processes that vary by insurer and clash with pressure to quickly discharge patients who no longer need hospital care. There’s also a lack of clarity about where there are open beds with staffing to take in newcomers and the types of patients that recuperative care facilities can serve. This confusion fuels referrals for people that facilities and insurers decide aren’t appropriate for the service and sometimes deters hospital staff from even seeking respite care for homeless patients.  

Nancy Behm, who until recently coordinated People Assisting the Homeless’ Medi-Cal-funded work in San Diego, said the nonprofit’s 14-bed recuperative care programs has seen its occupancy rate fluctuate since reforms took effect despite what she sees as a consistent need. From late November through January, Behm said about half of PATH’s recuperative beds sat empty. The past few weeks, the nonprofit said it’s been at or near capacity again – and it hopes that trend continues. 

“There’s a need,” Behm said. “We want these beds to be filled.” 

And if they aren’t, PATH and other providers risk losing them because they count on Medi-Cal funds to pay for the workers and amenities tied to them. 

Family Health Centers of San Diego senior vice president Jeff Gering, whose organization serves thousands of homeless patients, said the low number of recuperative care placements via Medi-Cal has given his nonprofit pause as it considers pursuing its own facility. 

“It’s a big risk,” said Gering, who remains convinced demand for recuperative care isn’t being met. 

Amid these challenges, county Supervisor Terra Lawson-Remer in January successfully urged fellow supervisors to invest $8 million to build a 100-bed recuperative care facility that she said could count on Medi-Cal reimbursements to fund patient care. 

The success of this model will rest on the region’s ability to work through existing snarls. There’s widespread agreement that the county needs more recuperative care beds – by one estimate, hundreds more – but existing facilities with dozens of beds aren’t always full. 

At least one hospital group, Scripps Health, argues Medi-Cal plans are now denying requests for recuperative care more than they should. 

“Recuperative care beds are a benefit many of our patients need, and that managed Medi-Cal is supposed to be providing, but they’re not authorizing this benefit enough,” said Melody Thomas, who oversees case management and social services for Scripps’ Hillcrest and Chula Vista hospitals. 

Meanwhile, UC San Diego Health spokeswoman Michelle Brubaker said that social workers in its hospitals often wait days for health plan approval. To cope, Brubaker said UCSD Health sometimes sends patients to an 11-bed recuperative care home for men where it leases beds rather than continue to wait on Medi-Cal plans after patients are medically cleared to leave the hospital. 

Absent signoffs from Medi-Cal plans, recuperative care providers typically can’t take in hospital patients unless they have contracts with hospitals – and for now, that isn’t the norm. This means homeless patients that hospital staff decided qualified for this service sometimes land in facilities less equipped to support them or back on the street, left to compete with dozens of others for a limited number of less-supportive shelter beds. Many who return outdoors end up back in local hospitals – and often, repeatedly. 

That’s what happened to 62-year-old Edward, who slept steps away from Scripps Mercy Hospital’s Hillcrest emergency room on a cold night in December after being discharged to the street. Edward, who asked that Voice of San Diego not publish his full name, is HIV positive and told Voice he stayed at Father Joe’s Villages recuperative care program for eight days after a prior hospitalization last fall. 

When Edward ended up back in the ER, he said Scripps Mercy staff tried to make arrangements with his insurer, Community Health Group, for a return to Father Joe’s 28-bed program. But Edward said Scripps staff told him his insurer wouldn’t allow it, forcing the 62-year-old back onto the street. 

State Medi-Cal policies generally allow for recuperative care stays of up to 90 days and don’t bar patients from returning to facilities if they are hospitalized again.  

Community Health Group didn’t respond to requests for comment about Edward’s experience, but Thomas said Scripps has seen this happen before. 

“These situations often are driven by how the insurance contracts are structured, and whether the patient adheres to the rules and requirements that are outlined,” Thomas said. 

Edward’s experience shows how state Medi-Cal reforms have increased the power insurers have to determine whether homeless Californians access recuperative care services.  

In San Diego, those insurers are now Blue Shield of California Promise, Community Health Group, Kaiser Permanente and Molina Healthcare. (Others have left the region the past couple years as part of broader Medi-Cal reform efforts.) 

The Newsom administration introduced state Medi-Cal reforms – initially dubbed CalAIM – in part to proactively link patients whose lives complicate their health conditions with services to help them stabilize. The initiative established community supports that insurers can offer recipients, including recuperative care. Insurers then secured contracts with providers to serve their clients.  

The rollout has been rocky in other parts of the state too. Last June, a California Health Care Foundation report documented Los Angeles County’s early struggles with eligibility and referral turnaround times. The report noted that L.A. County’s largest Medi-Cal plan initially denied recuperative care requests for emergency room patients. 

In San Diego County, the 2022 drop in recuperative care referrals led a group that includes the region’s three largest recuperative care providers, 2-1-1 San Diego and the local hospital association to begin meeting to discuss how to ensure the county didn’t lose beds reliant on Medi-Cal reimbursements. 

Since August 2022, the group has explored how to simplify the referral process. Among its recommendations: Temporarily presume homeless patients are eligible for recuperative care to speed the process to get them in, increase transparency on bed availability and institute a common screening option to help hospitals and others decide whether patients meet criteria for the service.  

Spokespeople for the state Department of Health Care Services said the agency has been working with Medi-Cal plans to try to increase access to benefits, including by encouraging Medi-Cal plans to assume presumptive eligibility for recuperative care. Effective Jan. 1, the agency also ordered Medi-Cal plans to remove restrictions on eligibility that don’t match state guidance. 

For example, Community Health Group previously required recipients to be enrolled in its plan for at least a year before they were eligible for recuperative care. 

DHCS spokesman Anthony Cava wrote in an email that the agency last June also hosted Medi-Cal plan staff at a summit that included one-on-one meetings where they could discuss “weaker utilization trends” for some CalAIM services. 

Two managed care plans told Voice they are trying to improve access to recuperative care.  

Kaiser Permanente, which reported using Medi-Cal to link just one San Diego County patient with respite care from 2022 through June 2023, wrote in a statement that it has since implemented presumptive eligibility for the service, provided trainings for staff to increase awareness about it and worked to simplify its referral form.  

“We are intent on taking the necessary steps to make CalAIM’s critical resources available and accessible throughout the communities we serve,” spokeswoman Jennifer Dailard wrote.  

Blue Shield of California Promise, which connected 85 patients with recuperative care from 2022 through June 2023, said it hired a program manager to support recuperative care placements early last year, has worked to minimize turnaround time for approval of referrals to no more than 72 hours and visited hospital staff to train them on their referral process. 

“Blue Shield Promise has seen improvements in placement turnaround times and bed utilization (increased placements) in 2023, and this improvement can be traced back to relationship building and education across our hospital partners and providers,” Dr. Jennifer Nuovo, the plan’s chief medical officer, wrote in a statement.  

Molina and Community Health Group didn’t respond to Voice’s requests for comment. 

Zachary Lenert, vice president of integrated case management for Sharp HealthCare, said the hospital group has recently had more success moving homeless patients into recuperative care. It’s now typically seeing Medi-Cal plans sign off on recuperative care stays within three days and has gotten better at lining up documentation insurers and providers need to keep things moving though there’s still confusion about plans’ differing processes. 

“I would say we’re trending in the right direction,” Lenert said.  

Filipa Rios, Interfaith Community Services’ chief program officer, said her nonprofit’s 91-bed recuperative care program has also seen positive shifts, namely more consistent referrals from insurers. 

Still, Rios said contracts that Interfaith has with Palomar Health and Tri-City Medical Center to set aside beds for their patients often serve as a bridge to allow homeless patients to move into recuperative care while they wait for insurance approvals. Once an insurer signs off, hospitals can send another patient to the facility. It’s a model that Rios thinks other hospitals in the county should replicate to increase access to respite care. 

For homeless patients, continued improvements could be a game changer. 

Robert Cowan III, 64, stayed at Interfaith’s Escondido recuperative care facility following knee replacement surgery at Scripps Memorial Hospital in Encinitas last fall. 

Cowan, who has Molina insurance, feared he’d end up on the street exposed to people who might prey on him while he tried to recuperate or in a packed shelter ill-equipped to serve him post-surgery.  

Cowan was relieved when he moved into the Abraham and Lillian Turk Recuperative Care Center, where he has a private room and bathroom. The respite program allowed him to meet with a nurse at least once a week, get rides to physical therapy and doctors’ appointments and work with a case manager on a plan to move to Nevada once he’s further along in his recovery.  

He felt safe and content. Earlier this year, he transitioned into a shelter program at the same site. 

“Being here, I’m very thankful,” Cowan said. “It’s like a godsend.”