“Bellevue Hospital has begun full evacuation to safely transfer all patients to appropriate care facilities,” read the notice posted on that hospital’s website Wednesday at 2 p.m. Eastern.

Thus began another chapter in the waterlogged saga of the hurricane formerly known as Sandy, downgraded to a super storm, as it continued well into Wednesday, moving across Pennsylvania and into Michigan and Illinois. In the meantime, in New York and New Jersey hospitals were coping with the aftermath of a storm that reportedly knocked out power to 8.2 million households in 17 states and caused at least 39 deaths in the U.S. alone.

Not only was the New York Stock Exchange closed for business from Monday until yesterday, but Halloween was also officially postponed by Mayor Michael Bloomberg, who also announced that 500 patients were being evacuated from Bellevue, considered to be the oldest continually running hospital in the United States.

Ironically, Bellevue, which on its website traces its history to being a haven for the indigent, brings to mind a very real contemporary challenge facing America’s hospitals and health systems today: caring for the homeless.

Since the harsh winters of 2010-11, hospitals have seen record numbers of homeless patients present at their doors, only to have many of them still residing in their facilities as the spring season unfolds.

Often the homeless are more acutely ill than many other patients, since they have limited access to healthcare resources on an ongoing basis, and as such they are prime factors impacting hospitals’ lengths of stay (LOS) and exposing them to additional RAC implications.

Moreover, the Great Recession has not discriminated against the homeless; it appears that everyone is fair game. And in many cases hospitals are seeing the fallout.

RAC Implications

When a patient continues to remain in the hospital without a place to go, the length of stay for that patient (as well as for the hospital) climbs almost exponentially. As this occurs, billing, reimbursement, coding, and medical necessity, among other factors, all come into play as RAC implications loom large. It is very important for hospitals to identify these patients early on in admissions, and to perform searches for relatives or file pleadings with the court to be sure the patient has a voice and protected rights as a safe discharge plan starts to take shape.

The Homeless Among Us

The cry for help by the homeless population is not falling on deaf ears in hospitals today; the matter is getting attention within the limited context hospitals can provide, given their depleted resources.

The National Health Care for the Homeless Council offers these tips for hospitals serving people experiencing homelessness during disasters:

  1. Have staff available to adequately address mental illness. In 2010, the U.S. Department of Housing and Urban Development reported that at least one in four (26 percent of) people experiencing homelessness had a serious mental illness (a conservative estimate based heavily on self-report). The tumultuous physical and social environment created when communities face a disaster can exacerbate symptoms of mental illness, particularly for people who have a history of trauma. Hospitals should have adequate professional staff and support available to treat acute episodes of mental illness just as they would for acute physical illness and injuries. However, unlike acute physical illness and injury, an acute episode of mental illness could be alarming and feel threatening to staff. Staff should be trained to recognize acute onset of mental illness, be able to communicate support in a calm and nonthreatening manner, and also be able to deescalate any potential conflict if needed.
  2. Partner with homeless service providers. Unlike hospitals, many homeless service agencies may close operations during a disaster. This can be particularly devastating for community members who depend on these agencies to meet their daily needs. As an alternative, individuals may seek support at hospitals. Consider developing mutual aid agreements with homeless service agencies to have staff members stationed at the hospital during times of severe weather or disaster, particularly when their offices are closed. Consider mutual aid agreements with Health Center Programs that have case managers, outreach workers, and clinicians trained to address the unique and complex health needs of people experiencing homelessness.
  3. Have a disaster specific hospital discharge plan in place. During disasters, hospitals are often overwhelmed and experience a higher demand for hospital beds. However, discharging people back to the street can have devastating consequences. Discharge workers should be aware of discharge options such as the Red Cross shelter, existing homeless shelters, or other homeless residential programs. Discharge workers should be able to describe these options to people who lack housing, address any concerns, be able to coordinate transportation to these agencies, and ensure that the agency is aware and able to accommodate the referral. Don’t wait until a disaster happens to develop a disaster-specific or homeless-specific discharge plan.
  4. Document housing status. Homelessness is a social determinant of health. As such, the International Classification of Diseases (ICD) includes a code for hospitals to document lack of housing (ICD-9, V60) for individuals seeking care. These codes are important for research and policy efforts addressing hospital utilization by people experiencing homelessness. See RACMonitor about documenting homelessness: http://www.racmonitor.com/news/27-rac-enews/722-addressing-homelessness-through-better-documentation.html.
  5. Take advantage of the Emergency Prescription Assistance Program (EPAP). EPAP is a federal program thatensures access to covered prescription drugs and durable medical equipment for eligible individuals who present at a pharmacy with a valid prescription, at no cost to the affected individual. During disasters, needed prescriptions may be lost or stolen. Hospitals can help people experiencing homelessness learn how to access free or low-cost prescriptions through the EPAP program. More information about the program is available here: www.phe.gov/Preparedness/planning/epap/Pages/default.aspx


Reporter’s Notebook:  Sandy’s Destruction Haunting

EDITOR’S NOTE: Mark Spivey is a correspondent for RACmonitor and ICD-10 who sent this text message on Tuesday as he surveyed the damage wreaked by super storm Sandy.

“Nearly 2.5 million customers are without power in New Jersey, worst in modern history following the storm. Downed trees and power lines are in the hundreds in our Central Jersey region alone. Lines out the door and down the street even at places like Dunkin’ Donuts because so few stores are open. Very few places to get gas. Also was horrible flooding from record storm surges on the coast and even in NYC; subways there are flooded and will take five days to get up and running again. All in all, it was easily the worst storm of its kind ever to hit NJ or NY. (President) Obama will be joining (New Jersey Governor Chris) Christie to tour the damage tomorrow. Also we are told to expect some power outages to last a week or longer.

The level of devastation really was incredible. I drove 20 miles this morning without seeing a working traffic light. Some neighborhoods had every single house with downed trees.”

About the Author

Chuck Buck is publisher of RACmonitor.

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