While preparing to write this piece about medically fragile homeless individuals, I came across a letter in my files from a local hospital that stated, “The above name patient is under my care for multiple co-morbidities including, but not limited to Obstructive Sleep Apnea, Coronary Artery Disease and Congestive Heart Failure. Due to his medical condition, he requires plenty of bed rest. If he does not get the needed bed rest, it will aggravate his condition. If his condition is aggravated, it may lead to hospitalization or even death.”
In recent months, many news outlets ran an article about a hospital in Baltimore putting a woman out on the street in a thin robe and socks. Unfortunately, this scenario has become all too familiar especially for those of us serving individuals experiencing homelessness. A patient unable to care for him or herself is “dumped” in the street or at a homeless shelter. The video alluded to in the article is horrifying. How can someone treat another human being like that one might ask? I don’t know, but what I do know is that when hospitals decide to “dump” patients on homeless shelters, it not only puts the patient’s health at risk, but creates a difficult situation for both the patient and those of us working with homeless individuals in the City’s network of emergency housing providers—shelters.
Similarly to the mission the City’s Office of Homeless Services (OHS) to provide the leadership, coordination, planning and mobilization of resources to make homelessness rare, brief and non-recurring, the mission of SELF, Inc. is to provide services to individuals, which enable them to achieve self-sufficiency in life management by developing strength of character and economic independence. As a partner with the City of Philadelphia, SELF operates a mix of emergency housing (shelters), transitional housing, and safe havens. On any given day, we serve approximately 500 homeless individuals with housing-related services including securing permanent housing, case management services, educational and skills building services and food services.
The Department of Housing and Urban Development (HUD) reported that, nationally, there were 306,000 people over age 50 living on the streets in 2014. Similarly, there has been a marked increase of homelessness among 18 to 24 years olds nationally and locally. One social determinant that ties these communities together is the issue of medically fragility. According to HUD, people living in shelters are more than twice as likely to have a disability compared to the general population. On a given night in 2017 , 20 percent of the homeless population reported having a serious mental illness, 16 percent of the conditions related to chronic substance abuse, and more than 10,000 people had HIV/AIDS. More and more, individuals experiencing homelessness are not only dealing with the much talked about opioid crisis gripping many of our communities, but increasingly homeless individuals are suffering from chronic diseases such as HIV/AIDS, heart disease, cancer, diabetes, spinal conditions and a host of behavioral health related issues. Further complicating the road to recovery from homelessness for many of these individuals are federal, state and local policies and practices that have historically adversely affected prevention and intervention efforts.
I am reminded of one recent participant who had end-stage colon cancer. A couple of days a week, he would make the trek to the hospital for treatment and return back to the shelter more weakened and closer to death. Our team inquired and advocated for more appropriate placement. Unable to secure more suitable placement, it was recommended by members of the participant’s care team that we allow hospice services to be provided for him at the shelter. SELF for years has prided itself on the humanity and dignity of our founder Dr. Sylvester Outley who battled his own demons and found SELF with a goal of improving communities one life at a time. Dr. Outley believed as we do that everyone deserves second, third, and even fourth chances. With this motivation, our team turned to the participant’s family and successfully advocated that he be allowed to go home where he could peacefully transition. A week later, he made his transition surrounded by family at home. Not long ago, an area hospital dumped a patient at one of our eight homeless shelters. The individual was physically weak and clearly incapable of taking care of himself and therefore shelter inappropriate. When we told the driver we could not admit the patient, the driver left before we could contact the hospital or make a more appropriate placement.
Increasingly hospitals are taking patients to emergency shelters when they need more extensive care.  Shelters do not have regular health care staff to care for those with chronic or other serious health care conditions.  Registered Nurses, Certified Registered Nurse Practitioners, and the like are not part of our regular staff.
If we did have the staff to care for ill or chronically ill homeless participants, we would without hesitation. The problem is we don’t, and with current stagnant funding levels and frankly decreasing political will facing the issue, I don’t see it in the near future. This is not just a Philadelphia problem or a Baltimore problem, it is a national problem. Hiring trained staff to deal with the medically fragile is a one viable solution. Another option is for the City of Philadelphia to enforce its policy that requires hospitals seeking placement for recently discharge patients to contact the Office of Homeless Service to refer and gain clearance for placement in City funded shelters. Unfortunately, too often this policy simply isn’t followed or enforced. To side step this policy often times hospitals will wait until later in the evening when City offices are closed to dump a patient on shelters. Because of the City’s policy push towards low barrier placement, many shelters are pressured to accept participants neither its facilities nor team members are adequately trained to care for.
It is our hope that programs that provide specialized services for medically fragile homeless individuals be given more consideration and that those in decision making seats in government will identify ways to strengthen partnerships with hospitals through policy, practice and if need be legislation to ensure that homeless individuals are afforded every humane opportunity to recover from homelessness.
Until then, our staff can do what it can, but we also need our partners in government and hospitals to do what they can and not release patients to the streets or to homeless shelters where staff cannot help them. We are in the business of caring for those who are vulnerable. I believe with increased communications and an integrated approach to determining who is shelter appropriate and who is not, we can all get on the same page and find adequate solutions for homeless individuals who have not only faced personal trauma, but too often systemic trauma.
Mike Hinson
Mike Hinson's Op-ed about patient dumping appeared in the Philadelphia Inquirer and on Philly.com. Please use this link to access: https://tinyurl.com/yae2s6gb