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					San Francisco Medical Respite:
Defining a Successful Discharge

     Michelle Nance, RN, NP - Midlevel provider
   Michelle Schneidermann, MD - Medical Director
  Shannon Smith, RN,MS,CNL - Intake Coordinator
      Alice Y. Wong, RN,CNS - Nurse Manager
                   Objectives
   Briefly describe the San Francisco Medical
    Respite Program
   Describe measures of success respite programs
    can use when evaluating discharges
   Describe the internal and external philosophies
    that influence discharge from medical respite
   Learn to identify and incorporate hospital and
    community needs into discharge planning
            Mission Statement
The mission of the Medical Respite Program is to provide
  recuperative care, temporary shelter, and coordination
  of services for medically and psychiatrically complex,
  homeless adults in San Francisco.
                       Values
We believe that:
 Every person has the right to housing, health care, and
  food security.
 All people have the right to self-determination.
 Every person is valued and entitled to dignity and
  respect.
 Homelessness is the result of a complex set of
  circumstances and necessitates a multifaceted approach
  toward resolution.
 A dedicated team can have a positive impact on the life
  of individuals and the community.
                           Vision
Our vision is to:
 Encourage healing and stabilization by providing respite from
  homelessness;
 Provide individualized assessment of client needs and a
  comprehensive plan of care;
 Advocate a harm reduction model to decrease the negative
  impact of unsafe behaviors;
 Provide compassionate, nonjudgmental, interdisciplinary, and
  state-of-the-art care;
 Collaborate with local entities to coordinate provision of care,
  options for housing, and initiation of entitlement process; and
 Forge relationships with local, regional and national networks of
  those who serve homeless persons.
The Vulnerable
& Medically
Complex
Homeless in SF
   SF Homeless Demographics
San Francisco Homeless Count 2007
   Done by SF Human Services Agency, March 2007
       African American/Black 47.6%
       Caucasian 43.4%
       Male 80.2%
       Female 19.4%
       Transgender 0.3%
   Sheltered Homeless
   Transitional Housing and Treatment Centers
   Resource Centers and Stabilization
   Jail
   Hospital
   Unsheltered count
   Total Count: n=6,377
         Health and Homelessness
   The average life expectancy of a homeless person is 42-
    52 yrs (average in US is 80 yrs)
   Homelessness magnifies poor health
       Exposes people to communicable illness and trauma
       Complicates management of chronic illness
       Makes health care harder to access
   Homeless patients are more likely to be seen in ED and
    admitted and have longer LOS than other patients
            Salit, S. et al (1998)
        The Hospitalized Homeless
   Treatment plans that make sense for housed
    patients don’t work for homeless patients
     No bed for bed rest
     Difficult to keep wounds clean

     Adherence to meds and appointments suffers

     Impossible to follow diet and exercise
      recommendations
     Often have no support system to help with
      treatment plan
        Hospitalized Homeless:
      The San Francisco Experience
   Around 20% - 30% of patients admitted to San
    Francisco General Hospital (SFGH) are
    homeless
   Most of those patients are chronically homeless
   Safe and effective discharge plans are difficult to
    construct
            What Respite Offers
   Successful resolution of acute conditions and
    stabilization of chronic conditions
   Linkages to additional services
   Development of plans focused on positive long-
    term changes
   Recuperation from not only physical illness, but
    also the emotional distress and isolation that
    accompany homelessness
Demographics of SF Medical Respite Program

   Ethnicity (and Gender):         Asian/PI           Filipino/a
                                               Other                Multiple
    Reflect homeless                  2%
                              AI/Alaskan
                                                2%
                                                           1%
                                                                    Ethnicity
                                                                      0%

    population of San            Native
                                  2%

    Francisco                   Latino/a
                                 12%
                                                                                Caucasian
                                                                                  45%

   Gender: 80% male/20%
    female                        African
                                 American
                                   36%
           San Francisco Hospitals
   The Medical Respite accepts clients from 10 area
    hospitals.
   San Francisco General Hospital and Trauma Center
       300+ bed acute care public hospital including only Level 1
        Trauma Center in San Francisco area.
   Nine other community hospitals
       Total: 2,200 Hospital Beds
             Referring Hospitals
           CPMC Davies   St. Luke's St. Mary's CPMC
              2%             1%         1%     California
        CPMC Pacific                              0% Kaiser
          Campus                                         0%
                                                    Other
            2%                                        1%
        St. Francis
            2%
         VAMC
           5%

        UCSF
         5%




                                                  SFGH
                                                   81%


Note: Other clients came from outpatient surgery and
 DPH case management programs
    Discharge Venues in San Francisco
Permanent Housing
 Direct Access to Housing (DAH)
        Supported (may include SW, CM, RN)
   Single Room Occupancies (SRO)
      Non-supported
      Supported (may include SW, CM, RN)

   Apartment/ House
           Discharge Venues
Shelter System
 GA Shelter Bed: 30-90 days

 A Woman’s Place shelter: up to 6 months

 City shelter: Case management; up to 6 months

 City shelter: No case management; 1 week
             Discharge Venues
   Higher Level of Care
     Board and Care
     Long Term Care Facility

     Emergency Department/ Inpatient Services

   Residential Treatment
   Hospice
       Discharge in the Literature
   Zerger, S (2006): Discharge standard of practice
    is that a client’s primary admitting diagnosis has
    been stabilized prior to discharge
   RCPN practice models state a safe discharge
    from respite care entails follow-up services
    Program Measures of Success: Short Term

    Completion of treatment plan, including
     demonstrated independence with self-care and
     medication management
    Improved living situation after discharge from
     Respite
    Engagement with primary care and specialty care
    Linkages to social services, benefits
    Referrals to mental health and substance abuse
     services
Medical Treatment Plan Completion

   Left or discharged
   prior to completing
        treatment
           35%

                                           Completed
                                           Treatment
                                              55%




                         Discharged to a
                         Higher Level of
                              Care
                              10%
Treatment Plan
Treatment Plan Completed!
     Length of Stay by Days and Disposition
   Disposition                    Mean (Days)   Median (Days)
    All Respite Clients            40            28
    AWOL                           14            5
    AMA                            17            11
    Supported SRO                  76            73
    Non-supported SRO or Shelter   32            21
    Completed Treatment Plan       55            47
    Did Not Complete Treatment     17            10
    Plan
  Discharge Disposition
       Violent Behavior     Inappropriate
              4%               behavior       Police Custody
AMA                              3%                 2%
 9%




                                                                   Self Care
      AWOL
                                                                     51%
       18%




                       ED
                      10%
                                               Medical Detox
                                                    1%
                Long Term Care
                      1%                             Residential
                                    Hospice
                                      0%             Treatment
                                                        1%
Linkages Made at Respite: Medical Services
                                80.0       73.7
                                       67.7                                             All Clients (n=421)
                                70.0
                                                         57.8                           minus AMA/AWOL (n=308)
                                60.0
  Percentage of Clients


                                                     52.7
                                50.0

                                40.0

                                30.0

                                20.0                                        15.2 15.6
                                                                                                                     11.4
                                                                  8.6 9.1                         9.5 10.7    10.7
                                10.0
                                                                                        2.1 2.6
                                 0.0




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                                                         Su
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                                                  In
                                   Linkages Made at Respite:
                                        Social Services

                        80                                                     75.6
                                                                        71.7
                                                           67.2                           All Clients (n=421)
                        70
                                                    62.7
                                                                                          minus AMA/AWOL
Percentage of Clients




                        60                                                                (n=308)

                        50

                        40
                                      32.8
                        30     25.9
                                                                                         23.3    23.7
                        20

                        10

                        0
                             Permanent Housing   Identification card   Income benefit   Medical coverage
                                                                                             benefit
Internal and External Philosophies
 External Philosophies: Hospital
“Enormous amounts of energy are spent re-
  stabilizing many of our homeless clients. Rather
  than successful long-term management we
  frequently are only treating acute exacerbations
  of the chronic conditions. Respite has been able
  to provide stability and management to many of
  our clients.”
                            - SFGH Attending Physician
 External Philosophies: Hospital
“We’d love to see people get into housing, especially the
  frequent flyers. However, we want to be able to refer
  more people and there is often a wait for a bed. So we
  can’t refer to you [Respite] if you do not discharge
  clients to shelter, as there are not enough beds.”

“The perfect discharge would have them go into some
  type of housing, an SRO. Transition back into the
  community in some sort of living situation, rather than
  back into the streets. But I know we don’t live in a
  perfect world.”
                          -SFGH Discharge Social Workers
 External Philosophies: Community
“Our homeless clients, in general, use our ambulances and
  EDs much more frequently than the typical housed
  client. In addition to overburdening the emergency
  medical service, this care does not address their long-
  term needs. They need access to regular medical care
  and medications, stable housing, psychiatric and
  substance abuse services, case management…The ideal
  scenario would be to establish all of this prior to their
  discharge. To give them a solid network of support.”
                          -San Francisco Paramedic Captain
 External Philosophies: Community
“We have few expectations of what you do for
 clients because we assume they don’t have
 anything. What we like about Respite is at least
 their medical linkage is done.”
           -SF HOT (Homeless Outreach Team) Case Manager
               Referral Difficulty
   Inpatient teams often express the enormous
    pressure they are under to discharge their clients.
       “We need to discharge today”
              Referral Difficulties
Inappropriate referrals lead to difficult discharges
 Need higher level of care than indicated
       Incontinence, dementia, not competent, not able to
        care for ADLs
   No acute medical need but a number of co-
    morbidities needing longer-term management
       What is the end point for discharge?
           Internal Philosophies
   Multidisciplinary staff:
     Nursing, midlevel providers, MD
     Administration
     Social workers
     Paraprofessional staff (medical assistants, health
      workers)
   How do we define a “good” discharge?
   How do our internal philosophies match our
    stated mission?
   What Is a “Good” Discharge?
“Our biggest discharge issue is the lack of available,
  affordable quality supportive housing.”
                                  – John Wiskind, LCSW

“In reviewing “success,” we look at whether people are
  still housed a year later.”
                                  – Mark Hamilton, MSW

“Individual housing is the gold standard”
                                  – Cindy Lee, RN
   What Is a “Good” Discharge?
“Completing the acute medical need, but that’s balanced
  with the need to more permanently offload burden
  from the emergency services and hospitals.”
                                – Michelle Nance, NP

“Completion of acute medical condition without being
  readmitted into the hospital.”
                                 – Shannon Smith, RN
   What Is a “Good” Discharge?
“A bad discharge is when we have to call the police. A
  good discharge is when we have done all we can do for
  someone.”
                    – Jeanne Andaya, MEA

“The acute medical need is done.”
                    – Tae-Wol Stanley, NP, Program Director

“The medical need is done, they are started with linkages,
  and discharged with reliable follow up”
                    – Alice Wong, RN, Nurse Manager
    What Is a “Good” Discharge?
“A good discharge means that while at respite, a patient has
  completed his/her treatment plan, engaged in primary care,
  learned self-care and medication management skills, and has
  begun the process of transitioning into permanent
  housing. There are some patients too vulnerable to be
  discharged from respite back to the shelter system and a
  successful discharge for those patients would include a move
  from respite directly into permanent housing. While in my
  fantasy world, all patients would discharge into permanent
  housing, the real world of limited resources forces us to triage.”

                       -Michelle Schneidermann, Medical Director
   What Is a “Good” Discharge?
“ At minimum: a resolution of a medical issue in an
  environment that is less costly and more normalized
  than the hospital. Even a short time (10-15 days) of
  recuperation that can be done at Respite rather than
  inpatient is cost saving. A good discharge is when a
  client leaves better equipped to find a next phase of a
  residential setting. I’d like to see direct uninterrupted
  access to a bed in the system, whether shelter,
  treatment, stabilization or permanent housing.”

       - Mark Trotz, Director, Dept of Housing and Urban Health
             Internal Philosophies
   Staff have different philosophies shaping their
    discharge decisions
       Can lead to confusion and conflict for both staff and
        clients
   Of note: no clients were asked for a definition
    of a successful discharge for this presentation
    Who Gets Prioritized for Housing?
   Older
       In our population, 50 years old is old
   Medically frail
   COPD requiring oxygen
   Hemodialysis
   Terminal or severe cancer diagnosis
   Amputation, paralysis
   “Tired”
       Done with the “player” lifestyle
       Willing to engage
   Most unstable/disruptive to system
   Heavy Emergency Services use
Pre-Hospital Living Situation
                Permanently
                  Housed
                    7%

        Homeless
       Transitional
          10%




                              Homeless
                                83%
Living Situation at Respite Discharge



        Permanently Housed
              28%




                               Homeless
                                 57%


       Homeless Transitional
              15%
               Living Situation
   51% of clients had a change in living situation
    for the better
   44% of clients had no change in living situation
Is Individual Housing the Gold Standard
             of a Discharge?
“What a lot of clients need is a mom and that’s what they
  get at Respite: nagging, reminders, family and friends,
  increased social interactions, meals. They lose this in
  housing.”
                                 – Cindy Lee, RN

“We tend to think of housing as the gold standard, but for
  many clients having an individual room doesn’t work –
  they decompensate in that situation.”
                                 – John Wiskind, LCSW
    Is Housing the Gold Standard?
   Supportive Housing (SH) programs become less
    willing to take our clients because the clients are
    too sick/disorganized
   SH asked to be “hospice lite;” staff gets
    overburdened and burned out
   Should we prioritize “less sick” clients for SH
    instead of the most fragile so there’s more
    success?
   Are there other options?
                             Next Steps?
   Creating more communal living situations
       Smaller group homes with support services
       Encouraging community in SROs
   Foster creation of Medical Rest Beds in Shelters
       For clients who are awaiting housing
       Communal living
       Medical/social support
       Free up Respite beds for acute needs
   Get more data
       Who do we really house?
       Outcomes for housed
            Objective: 911 calls, hospital readmits, evictions
            Subjective: client’s perceived mood, substance use
                     Next Steps?
   Re-examine our internal philosophies on
    discharge
   Create more objective measures for who we
    hold for housing
     Assessment tool
     “transplant waitlist”

   Formalize team discussions of referrals
       e.g., a “tumor board” for housing
   Respite Alumni Network
    Incorporating These Philosophies
        into Discharge Planning
   Identifying when housing IS the gold standard
    and appropriate
       Ex: Client is medically complex and ready to engage
   Triaging and creating individualized discharge
    plans based on medical and psycho-social need
    and willingness to engage
   Education and understanding that sometimes a
    successful discharge does not include a direct,
    uninterrupted discharge to housing
Case Studies
                      Mr. B
   66 year-old man with a long history of asthma,
    COPD, asbestos exposure, tobacco and alcohol
    abuse, and depression, who was admitted to the
    hospital for pneumonia.
   X-ray and CT scan of the chest showed large
    masses in his lungs
   Confirmed to be extensive small cell lung cancer
   Started on chemotherapy and transferred to
    Medical Respite 6 days later…
              Mr. B: At Respite
   Admitted on January 31, 2008 for assistance
    with follow-up chemotherapy treatment and
    appointments
   Stayed at Respite for 78 days until discharge into
    Supportive Housing
   Stopped drinking
   Reconnected with his daughters in OK
             Mr. B: After Respite
   Came back to visit and showed us pictures of his
    granddaughters after a visit to see his family in OK
   Had last day of chemo and decided to celebrate
   Relapsed for 9 days when his case manager finally
    found him
   Was admitted to a detox facility
   Returned to supportive housing
   January 2009: entered hospice care
   March 2009: Mr. B died in hospice
                         Mr. M
   33 year-old man with a history of poorly controlled
    diabetes, polysubstance abuse, depression, post-
    traumatic stress disorder, schizoid personality disorder,
    admitted to the hospital for DKA.
   Immigrant from DRC
   History of being boy soldier, imprisonment, and torture
   Poor adherence to insulin regimen
   Admitted to Respite for stabilization of blood glucose
    levels while awaiting follow-up appointment with
    primary care provider
              Mr. M: At Respite
   Challenges
     Cultural Issues
     Complex psychiatric history
     Brittle diabetic

   Behavior at Respite
     Compliant with medication regimen and medical
      needs
     Patient split between professional and
      paraprofessional staff
     Threatened to kill a Respite Worker
What Would You Do?
                 What We Did
   No tolerance policy for violence
   Partnered with patient’s pre-existing case
    manager
   Behavioral contract until case manager could
    find alternative place
   Capitalized on respect for clinical staff to
    continue managing his medical need
   Case manager was able to secure a 28-day
    stabilization room 24 hours later
                             Mr. C
   52 year old man with history of CHF, CAD, CVA with L
    hemiparesis and slurred speech; w/c bound; hidradentitis
    suppurativa; microcytic anemia; HTN; Hep B; Hep C. 35 pack-
    year tobacco history; denies ETOH or SA
   Left buttock wound with fistula
   Staying in shelters and had been unable to do wound care on
    own so presented to the Wound Care Clinic.
   Was hospitalized for a left buttock abscess and fistula
   Referred to Respite for ongoing wound care of the perirectal
    area and bilateral buttock and to f/u with PCP for his microcytic
    anemia.
   Also needed IHSS worker
                 Mr. C: At Respite
   Respite cannot offer a hospital bed
   Was not independent with bathing: required two-person assist
    with bathing and wound care
   Not always compliant with wound care and hygiene
    recommendations
   Lost Section 8 housing and wait list was long for ADA room
   IHSS worker would be helpful, but needed housing first
   Wound began to worsen
   Was found with frank blood soaked through clothes and sheets
    on bed from the wounds
What Would You Do?
                      At Respite: Mr. C
   Engaged with Mr. C’s primary care provider
   Wound was to extent it needed surgical repair
   Even if Mr. C went to housing with IHSS, an IHSS worker could
    not offer the kind of care the wound needed
   Issues:
       To high level of care for Respite
       With the PCP we decided to discharge
            pt’s choice - shelter or hospital for FTT
   Agreed to admit to SFGH for FTT
   Respite Case Manager recently saw him at SFGH walking in the
    halls with a walker!
                       Mr. A
   62 year old male s/p R hip fracture, hx of
    ETOH
   Admitted first to Respite and went AWOL the
    same day
   After 48 hours a hospital search found he had
    fallen while acutely intoxicated and refractured
    his hip
   Readmitted to Respite 1 week later
              Mr. A: At Respite
   Engaged with FSA Case Manager
   Decreased ETOH intake
   Gained weight
   Expressed desire for treatment program
   Respite challenge: 290 status (sex offender)
             Mr. A: At Respite
   Realities of 290 status in San Francisco
   No inpatient treatment program in SF takes 290
    status
   Shelters discharge someone with 290 status
   No inpatient treatment program in Alameda
    County will take 290 status, either
What Would You Do?
                      Mr. A
   Medical Treatment Plan completed
   Engaged with primary care provider who he sees
    when he doses
   Went to stabilization room through FSA case
    manager
   Detox and ETOH treatment plan left to primary
    care provider
                     Ms. L
   84 year old female with history of HTN, Afib,
    anemia, and CHF
   This was her only hospital admission on record
    at SFGH
   Admitted to Respite to finish antibiotics for
    BLE cellulitis
   No family involvement. Her only child and only
    sister have both died.
               Ms. L: At Respite
   Finished antibiotics
   Received wound care
   Engaged in primary care through Bridge Clinic
   Through ongoing primary care she became more
    medically complex and unable to self-manage her
    medications
   Accepted into supported senior housing in brand-new
    building
   Ms. L refused this housing stating, “it’s too new.”
   Found competent and not conservable
What Would You Do?
                      Ms. L
   Had 122-day length of stay
   Bridged primary care to Curry Senior Center
    that provides case management to low income
    seniors
   Discharged to shelter with case management
    through Curry Senior Center
   Respite received sad news: Ms. L died at St.
    Francis Hospital on May 1, 2009
        So: What Is the Definition of a
          Successful Discharge?
   No single definition of a good discharge
   We have identified two different conceptions of
    a good discharge
     Client discharges to a specific place
     Client has received services and links to services
      during stay
   In your community you have to balance your
    external and internal philosophies
Thank You

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Description: Medical Manager document sample