“We know that homeless patients have longer lengths of hospital stay because their discharges are fraught with problems,” she says. A homeless patient hospitalized with a blood clot potentially could be kept in the hospital for a week while transitioning from heparin to Coumadin, while similar patients with community support might get discharged in a day.
“We are also fortunate to have a program called Healthy San Francisco,” which isn’t a health insurance program per se but since 2007 has provided access to outpatient, inpatient, and preventive care and medications for indigent patients, Dr. Schneidermann says. Sponsored by the city’s Department of Public Health, it is accessed through 32 medical homes located in both public and private clinics. The hospitalists’ goal is to have a follow-up appointment set with a receiving provider at the time of discharge. “It doesn’t always happen, but that’s the goal,” she explains. “Someone, by name, who has accepted the referral.”
Dr. Critchfield is running a randomized controlled trial of the hospital’s interventions to stem the tide of readmissions in patients 60 and older; many of these patients share the same indigent demographics of the rest of San Francisco General’s caseload, although most patients 65 and older qualify for Medicare. He describes the program as a hybrid of Project RED and Dr. Coleman’s Care Transitions Program, although it targets patients who speak English, Spanish, Cantonese, and Mandarin.
How many Americans are uninsured today is a moving target in the context of healthcare reform and its uncertain future, but the number increased to 53 million in 2007 from 42 million in 1998.4 The number of hospitalizations of uninsured patients also grew to 2.3 million from 1.8 million in the same time period, an increase of 31%, while total hospitalizations were increasing by 13%. A May 2011 research brief from the U.S. Department of Health and Human Services estimates that uncompensated costs of hospital care incurred for uninsured patients total $73 billion per year.5
The homeless in shelters or on the street number about 630,000 on any given evening, and 1.5 million Americans experienced homelessness last year, says Sabrina Edgington, MSSW, program and policy specialist at the National Health Care for the Homeless Council in Nashville, Tenn. That said, 30% of the U.S. homeless have health insurance. Uninsured patients are less likely to receive necessary diagnostic tests and labs while in the hospital, and they face limited access and longer wait times—even in the facilities that are willing to take them.7 Research published in the Journal of Hospital Medicine finds that uninsured or Medicaid patients with three common conditions are more likely to die in the hospital than insured patients.8 A 2008 national sample survey of physicians found that “most U.S. physicians limit their care of medically indigent patients.”9 Other recent research suggests that readmission rates are affected by race and by site of care—with hospitals serving a higher proportion of black patients also having higher readmission rates.10
“This is not a hospital problem—it’s a communitywide problem. So there’s not just a hospital solution; it will take the whole village,” says Patricia Rutherford, RN, MS, vice president of the Institute for Healthcare Improvement (IHI), which sponsors initiatives targeting care transitions.
The major national care-transitions programs that assist hospitals with addressing rehospitalizations all share similar objectives, Rutherford says, and all could be helpful in improving hospitals’ responses to indigent patients. The recognized programs include IHI’s STAAR (State Action on Avoidable Rehospitalizations: www.ihi.org/IHI/Programs), a multistate, multistakeholder quality improvement (QI) program; Project BOOST; Project RED; Dr. Coleman’s Care Transitions Project; the nursing-based Transitional Care Model (www.transitionalcare.infowww.cardiosource.org).
