How to improve discharge procedures for homeless patients

Arrowhead Regional Medical Center improves discharge procedures for homeless patients.

When people think of life in California, they often think of movie stars, mansions, and pristine beaches. The reality can sometimes be less glamorous. Since 2016, the homeless population in California has risen by 13 percent. There are now an estimated 130,000 homeless individuals living across California, including 50,000 in Los Angeles alone. Walking the streets in San Bernardino County, the sight of people sleeping in cars, under bridges, and in parks is all too common. 

With nowhere else to turn, many visit hospitals to obtain basic necessities. Yet the procedures for discharging these patients aren't always clear. In some cases, overburdened hospitals are forced to discharge patients back onto the streets. This creates an ongoing cycle of ED overuse that puts a strain on hospital resources, and does little for the long term wellness of these patients. 

In response to these mounting issues, California, Oregon, and Colorado all passed laws in 2018 which mandated clear procedures that hospitals need to follow when discharging homeless patients. Like other hospitals across the state, we at Arrowhead Regional Medical Center needed to alter our procedures to ensure that this population had better access to the resources and follow-up care they need, without relying solely on the ED. 

Legally, Arrowhead now has to complete the following steps when discharging a homeless patient:

  • Identify the patient and maintain a tracking log
  • Make an effort to track down next of kin
  • Provide weather-appropriate clothing
  • Provide a meal upon discharge
  • Provide a 30-day supply of medications or a prescription
  • Look at options for local shelters
  • Provide a discharge report written at a fifth-grade level
  • Provide transportation up to 30 minutes or 30 miles away—not to the street, but to a fixed location.

Using MEDITECH assessments, we are now able to identify and track our homeless patients, with different assessments built into each of our three EDs (regular, behavioral, and labor and delivery).

The assessment begins with questions to determine if a patient is homeless. For example, “Do you have a permanent place of residence?” or “Do you stay or sleep on the street?”

If a patient is identified as homeless, clinicians are then prompted to capture additional details, such as the patient’s assessment and next of kin information. It’s then up to case managers and social workers to track down a safe place to discharge the patient, document where they are going and how they will be transported, and record discharge notes and prescriptions. 

Using analytics, we can track the volume and frequency of these visits, and any readmissions. With this information, we can start to identify trends and analyze the impact of our efforts. 

In addition to these new procedures, we looked at some of the common reasons that homeless individuals were avoiding or misusing the ED, and tried to find solutions. For example, one hospital found that some avoided the ED because they were afraid that their belongings would be confiscated. The hospital responded by documenting patient belongings in their system, and providing a secure storage space to ease these concerns.

We also discovered that many patients were unaware of our services, or had no means of transportation to the hospital. We now have two mobile clinics that visit rural areas and areas with large homeless populations, and administer care to anyone in need. 

We’ve experienced no negative feedback from our providers about the additional screening required, nor any negative feedback from patients. The assessment and discharge process appear to flow seamlessly through the MEDITECH assessments.

Homeless rates are still on the rise statewide, but we have reasons to feel optimistic. Our county recently received grant funding that will go towards outreach programs, including the conversion of former hotels into housing units for the homeless. Having a fixed address is absolutely crucial for individuals attempting to apply for jobs or to receive food stamps.

We hope that the laws passed in California, Oregon, and Colorado will inspire hospitals in other states to rethink the way they care for homeless patients. Making sure that these patients get the follow-up care they need to keep them healthy and out of the ED is a win for hospitals, and their communities. 


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Topics: Population Health, Patient Engagement, Social Determinants

Written by Audrey Premdas, RN, BSN, Clinical Informatics, Arrowhead Regional Medical Center

Audrey has been a registered nurse for 39 years, including 28 years spent as a NICU nurse, helping to save the lives of the hospital's most fragile patients. For the last eight years, she has worked at Arrowhead Regional Medical Center as a Clinical Information Technology RN. In this role she enjoys the challenges of building, modifying, and maintaining MEDITECH for the end-users. Most importantly, she is the mother of one son, Marshall.