Other issues disproportionally impacting uninsured or indigent patients include low literacy, low healthcare literacy, language barriers, cross-cultural barriers, substance abuse and mental health issues, homelessness or marginal housing, transportation barriers, and “social isolation, which also plagues our population and, I believe, places patients at risk, as does depression,” says Dr. Critchfield’s colleague Michelle Schneidermann, MD.
One-third of San Francisco General’s patients are uninsured and 40% have Medi-Cal (California’s version of Medicaid), which basically means they are underinsured.
“California has 19 safety-net hospitals, with 6% of the state’s inpatient beds but 50% of its uninsured population. So that’s what we do,” Dr. Critchfield says. But almost any hospital or hospitalist will see many of the same issues and problems, just not in the same proportions. “These are patients who can be most frustrating to hospitalists, requiring a disproportionate amount of our time,” he says, adding the greatest difficulty is helping these patients understand and follow post-discharge care plans. But if someone is ill enough to need acute hospitalization and is later discharged back to the street, readmission should not be a surprise. “We’ve done that experiment for many years, and we know how it turns out,” he says.
Dr. Schneidermann serves as medical director of San Francisco General’s medical respite program, a 45-bed emergency shelter that accepts homeless or marginally housed patients in need of follow-up care following discharge from any of the city’s acute-care hospitals. Research has shown that the programs can have a major effect on keeping discharged patients off the street, reducing their rates of rehospitalization by as much as 50%.2,3
