s-edgingtonThe term “discharge planning” appears in the language of the Patient Protection and Affordable Care Act of 2010 multiple times (nine times, to be exact). The hope is that effective discharge planning will improve quality of care and reduce readmissions, thereby cutting costs.


Indeed, group insurers will be expected to report on benefits and reimbursement structures that support activities to reduce readmissions, with reports expected to reflect a comprehensive program for hospital discharge. The act describes these programs as including patient-centered education and counseling, comprehensive discharge planning and post-discharge reinforcement by an appropriate healthcare professional.


The responsibility for much of this work will fall on the shoulders of hospital discharge workers. Such workers will have to jump hurdles to ensure that their most frail and vulnerable patients will be able to follow through on physician instructions with minimal resources.


Consider, for example, a homeless person undergoing chemotherapy. A discharge worker no doubt would attempt to help such a patient access suitable housing. Unfortunately, waiting lists for housing often are years long. As such, the patient likely would be referred to a homeless shelter, which is probably closed during the day and lacks the staffing and facilities to assist someone who is ill, much less someone who needs assistance with a chemotherapy regimen. With nowhere to go, the patient may attempt to rest on a bench or sidewalk and risk being arrested for loitering. This scenario is an everyday occurrence, and more than likely the patient would end up back in the hospital for complications that could have been avoided had adequate resources been available.


Readmissions Problems


Frequent readmissions by people experiencing homelessness do not represent failures of discharge workers. Such workers are expected to help patients access resources and services that often are unavailable in their communities. Though discharge workers play a key role in quality of care, more systemic issues need to be addressed to ensure that the most disenfranchised of patients are able to access needed resources and break the cycle of frequent hospital readmissions. Unfortunately, access to necessary services is not likely to improve anytime soon. Deficit reduction strategies proposed by Congress more than likely will put a squeeze on most federally supported housing and social-service programs.


Hospitals increasingly are becoming aware of the link between poor health and lack of housing, and many are taking the initiative to address systemic barriers that perpetuate this correlation. As such, a number of hospitals across the country have joined community-wide efforts to address this matter. Hospitals not already engaged in efforts to improve healthcare delivery and efficiency for people experiencing homelessness may want to consider one of the initiatives described below. Links to organizations that can help facilitate participation in these initiatives are included in the descriptions.


Triple AimThe Triple Aim initiative is a program of the Institute for Healthcare Improvement (IHI) that aims to improve the experience of care, enhance the health of certain populations and reduce per-capita costs of healthcare. The program coordinates the pulling together of community resources in order to optimize systems for defined populations. Don Berwick, former president and CEO of IHI (and current administrator of the Centers for Medicare & Medicaid Services), describes the Triple Aim initiative in an article he authored in a 2009 issue of Health Affairs.


100,000 Homes Campaignthe 100,000 Homes Campaign establishes community partnerships to bridge healthcare and housing services, coordinate care, and leverage resources. Hospitals participating in the 100,000 Homes Campaign help identify extremely vulnerable patients using something called the Vulnerability Index, a simple tool that uses health information and utilization information to assess vulnerability and risk of death. Individuals who are the most vulnerable are prioritized for housing placement and linked to a medical home where a team of clinicians provide and coordinate care.


Collaborations to increase access to medical respite care –Medical respite programs provide medical care to people (generally homeless people) recovering from an acute illness or injury whose conditions would be exacerbated by living on the street, in a shelter or in other unsuitable places. Combined with housing placement services and effective case management, medical respite programs allow individuals with acute or complex medical and psychological or social needs to recover in a stable environment while reducing potential complications and subsequent hospital admissions. Nearly half of the medical respite programs in the United States receive support from hospitals either through annual contributions or payments rendered per referral. Not only do medical respite programs provide hospitals with an immediate discharge option for their homeless patients, research finds that participation decreases future hospitalization by 50 percent compared to such patients who do not have access to such care.


About the Author


Sabrina Edgington, MSSW, is the program and policy specialist for the National Health Care for the Homeless Council. She is a frequent contributor to RACMonitorEnews and Monitor Monday podcasts.


Contact the Author




To comment on this article please go to editor@racmonitor.com


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Buchanan, D., Doblin, B., Sai, T., & Garcia, P. (2006). The effects of respite care for homeless patients: A cohort study. American Journal of Public Health, 96(7), 1278–1281.


Kertesz, S. G., Posner, M. A., O’Connell, J. J., Swain, S., Mullins, A. N., Shwartz, M., & Ash, A. S. (2009). Post-hospital medical respite care and hospital readmission of homeless persons. Journal of Prevention & Intervention in the Community, 37(2), 129–142.

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