New California Legislation Aims to Improve Discharge Planning for a Vulnerable Patient Population

To describe homelessness as a “complicating factor” in healthcare is a gross understatement; the homeless die nearly three decades earlier than the general population and their health challenges are innumerable.ⁱ Addiction, mental illness, malnutrition, exposure to a host of infectious diseases related to overcrowding, poor hygiene, a lack of sanitation and IV drug use as well as the threat of violence, routinely undermine the health and wellbeing of this population.  For the homeless, healthcare access is at best-episodic and is often driven by the need for urgent treatment.

Studies estimate that those experiencing homelessness are four times more likely than low income residents to use emergency room services.ⁱⁱ A lack of access to primary care and preventative health services, places homeless patients at increased risk for late stage diagnosis of disease.ⁱⁱⁱ  Mental illness, common in this population, coupled with logistical and economic challenges make the management of chronic diseases such as asthma and diabetes nearly impossible. Understandably, healthcare professionals are confounded as to how to effect sustainable improvement in the health and wellbeing of their homeless patients.

California is home to over one-quarter of the nation’s homeless, roughly 114,000 -130,000 people, and the number is expected to increase.^iv  Although overcoming the health disparities of homelessness defies easy solution, recent legislation focusing on treatment, screening, and improved care coordination with social services and community partners, may help ease the transition for homeless patients at discharge.  

In 2018, in response to news stories of homeless patients unfit for discharge being “dumped” on skid row, Governor Brown signed legislation requiring hospitals to expand current efforts surrounding discharge planning for homeless patients.

Effective January 2019, SB 1152 requires hospitals to establish a homeless patient discharge planning policy incorporated into the current discharge policy or included as an addendum.  The purpose of the policy is to create an individualized discharge plan for homeless patients to “help prepare the homeless patient for return to the community by connecting him or her with available community resources, treatment, shelter and other supportive services.”

The following are a few of the key provisions in effect since January 2019:

• Housing/Shelter: Hospitals must inquire about a patient’s housing status and identify a post discharge destination for the patient.  Unless a patient requires continued care at another licensed health facility, priority should be given to a sheltered destination with supportive services. 

Prior to discharging homeless patients, hospitals must offer the following services: 

• Medical Screening Exam: Treating physicians must provide and document a medical screening examination and evaluation of the patient (an existing requirement under EMTALA) and assess whether the patient is oriented to person, place and time. Physicians must also determine a patient’s clinical stability for discharge.
• Post-Discharge Care and Referrals:  In a culturally competent manner and in language that is understood by the homeless patient, healthcare providers must communicate post-discharge needs to the patient and refer the patient for follow-up care.  If behavioral healthcare is needed, the patient shall be treated or referred to an appropriate provider.
• Contacting Health Plan, Caregivers, and PCP:  The hospital must demonstrate good faith efforts to contact the patient’s health plan, if they are currently enrolled; the patient’s identified primary care provider; another appropriate primary care provider, including but not limited to a coordinated entry system.
• Screening for Affordable Health Coverage: Hospitals must provide screening and assistance enrolling patients in any affordable healthcare coverage for which they eligible.
• Infection Disease Screening: Hospitals must offer screening for infectious diseases common to the region or refer the patient for screening at a county clinic.  Hospitals may consult with the local public health officer for guidance on appropriate screenings.
• Vaccines:  Hospitals must offer vaccinations appropriate to the patient’s presenting medical condition and provided the federal vaccine information statement.
• Nutrition: Hospitals must offer patients a meal before discharge.
• Clothing: Hospitals must assess if the patient’s clothing is “weather-appropriate” and offer appropriate clothing as needed.
• Medications: Hospitals must provide prescriptions to homeless patients requiring medication.  Further, if the hospital has an onsite pharmacy licensed to dispense outpatient meds, the patient must be given an appropriate supply of all necessary medications.
• Transportation:  At discharge, the hospital must offer homeless patients transportation to discharge destinations within 30 miles or 30 minutes from the hospital.

Additional Requirements to Coordinate Services and Referrals - Effective July 1, 2019

In addition to the requirements outlined above, by July 1, 2019 hospitals must implement a written plan for coordinating services and referrals for homeless patients with community partners including county behavioral health agencies, healthcare professionals, regional healthcare and social services agencies, and nonprofit social services providers.

Finally, the hospital must maintain a log of homeless patients and their discharge destinations and must document compliance with the discharge protocol.

For further information on this subject, see the California Hospital Association guidebook Discharge Planning for Homeless Patients at https://www.calhospital.org/cha-news-article/homeless-patient-discharge-planning-guidebook-now-available-free-download