Sunday, August 3, 2008

Hospital patients who can't (or won't) leave

Immigrants Facing Deportation by U.S. Hospitals” reports today’s New York Times about the extraordinary efforts of one Florida hospital to find continuing care, both in this country and in the patient’s native Guatemala, for an illegal immigrant who had become a de facto ward of the hospital.

Last week the Wall Street Journal reported that a Los Angeles’ ordinance makes it illegal for city hospitals to discharge to “skid row” homeless people who no longer need to stay in the hospital – this is called “patient dumping.” See “L.A. Law May Keep Homeless in Hospitals.” According to the Journal, many homeless patients simply “refuse to leave” a hospital.

Hospital, a new book by Julie Salamon, which is highly recommended, recounts the efforts of discharge planners at Brooklyn's Maimonides Hospital to find a place for a Chinese immigrant who, dying of cancer, no longer needed hospital-level care but otherwise had nowhere to go.

Hospitals nationwide deal with such situations all the time. Once a hospital has successfully cared for an individual’s acute care needs, that person may end up with nowhere to go because of deficiencies and inconsistencies in health care and social service systems.

A family may drop off an elderly parent in the emergency room, then leave on vacation or refuse to take the parent home after discharge from the hospital. If no nursing home will accept the patient, that individual becomes a border in the hospital, sometimes indefinitely.

Hospitals often help patients and families with nursing home placements by assisting with the complex Medicaid application process. It is not unusual, however, to find an individual or a family unwilling to disclose financial assets – unwilling even to sign a Medicaid application. This often means a nursing home will not accept the patient, who then remains inappropriately in the hospital.

These are called placement, transfer, or discharge problems, and few know about or understand them. As a result, such problems generate no political consensus toward a solution.

As a humane society, how do we assure appropriate levels of care for the homeless, for illegal immigrants, for the mentally challenged, as well as for those who may be willfully irresponsible?

According to the Journal: “[A]bout half the hospital’s homeless patients won’t sign discharge consent forms. ‘We can’t force them,’” says the discharge planner at one California hospital.

The Times reported that the Florida hospital’s care amounted to $1.5 million for the Guatemalan patient, but when it came to paying for nursing home or rehabilitation care, the hospital declined “to take out…[its] checkbook.” Why was that expected to be a hospital responsibility? Hadn't the hospital already discharged its (uncompensated) responsibility for acute care? Where is the nursing home industry's responsibility for continuing care? Where is the US government’s responsibility? Where is the responsibility of Guatemala for one of its citizens?

Government rules and media scrutiny are inconsistent among the sectors of the health care system. Thanks to unaligned incentives and inconsistent requirements, our disjointed health care system yields paradoxical results, as reflected in these stories from the Times and the Journal.


tony marsallo said...

Tom, I hope that our community realizes how strong your committment is to quality healthcare and quality of life for that matter. Your efforts and dedication to a very complicated business are truly awesome.
Tony Marsallo

Tom Quinn said...

Thanks, Tony. Health care is a complicated system, the quality of which is highly dependent upon good people, having good skills, and working with good processes.