Patients Who Can't Fill Prescriptions

[docB]

Here's the scenario. You have a homeless patient who presents with a productive cough. He has an O2 sat of 97%. He is a smoker. His chest X-ray shows an infiltrate. You discuss your plan with the patient which is discharge with a prescription for antibiotics. The patient says he has no money, net even $4 for antibiotics.

Do you discharge the patient with the prescription or do you admit the patient for antibiotic treatment.

For the sake of brevity I have limited the poll choices to "Admit" or "Discharge." Feel free to discuss your reasoning such as "Discharge because at my shop the admitting doctor would refuse the admission."

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[deleted109597]

Send them home. Hospital will often give a week of free meds to avoid the admission. Just no narcotics.

 

[GeneralVeers]

Send them home. Hospital will often give a week of free meds to avoid the admission. Just no narcotics.

Agreed. I had one of these annoying patients with "cyclic vomiting syndrome". She was a female in her 40's who had been admitted about 10 times for it. In addition to dilaudid, the only medicine that helped her was Zofran, which she said she couldn't afford. She was demanding admission stating that without Zofran she couldn't keep anything down, and since she couldn't afford it we had to admit her. She really wanted admission so that the admitting doc (who's a sucker) would give her IV narcotics. I resolved the situation by having the social worker arrange to give her 10 pills of Zofran for free. Needless to say the patient was very pissed off that her plan failed.

 

[Hamhock]

Discharge.

At all costs.

I'd give the guy $4 dollars, a map to Target, and document this.

HH

 

[Aesculapius]

Don't many chain pharmacies give out certain antibiotics for free nowadays, anyway?

I also love the "is smoker" + "not even $4 for antibiotics".

 

[southerndoc]

A lot of homeless are alcoholics, and are susceptible to MDR bacterial pneumoniae (including Klebsiella).

If there's an infiltrate, I almost always admit them for big gun antibiotics.

 

[GeneralVeers]

A lot of homeless are alcoholics, and are susceptible to MDR bacterial pneumoniae (including Klebsiella).

If there's an infiltrate, I almost always admit them for big gun antibiotics.

If someone is a smoker or an alcoholic then they can afford cheap antibiotics. There is a big difference to me between patients who won't fill a prescription versus those who can't.

 

[EctopicFetus]

Simply put we have social work. I am a believer that to some extent our job is to not screw the system out of tons of money. That being said I also would give this dude $4 out of my wallet to avoid the admission. Where I work we usually have social work who can resolve this as well.

 

[deleted109597]

MDIs are another big issue with this. Many self pays can't afford the new albuterol since the FDA said the old ones were killing that ozone, and now it costs $90. The hospital still saves almost $900 to give them out vs admitting them for q4 albuterol nebs. I hand them out like candy.

 

[deleted109597]

A lot of homeless are alcoholics, and are susceptible to MDR bacterial pneumoniae (including Klebsiella).

If there's an infiltrate, I almost always admit them for big gun antibiotics.

7 days of PO avelox is still cheaper than 1 day of hospitalization.

 

[StevieStud]

Wally doesn't sell beer in my town so keeping a stash of $4 gift card is always helpful to overcome these issues.

If Wally sells beer then forget the gift cards because we all know for what product the money will be spent.

 

[southerndoc]

7 days of PO avelox is still cheaper than 1 day of hospitalization.

Not necessarily. Avelox is expensive to the homeless person, and although you could argue it's cheaper for the hospital to just buy the Avelox, it's actually more expensive because they can't write it off as easily as non-reimbursed hospitalizations.

 

[EctopicFetus]

doxycycline is a good option.

 

[Apollyon]

See, it depends on where you are for a big part. In this thread, Las Vegas, Texas, Arizona, Florida (I thought - maybe not), and Atlanta are all represented. In my Hawai'i practice, I get no guff from the hospitalists to admit someone with objective findings with no follow up.

Maybe we just need the "asses in the seats" at my place.

 

[EctopicFetus]

I get no gruff either but I dont want to fill the hospital with this BS.

 

[Apollyon]

I get no gruff either but I dont want to fill the hospital with this BS.

Cough and infiltrate in a smoker who is unreliable is BS? Just because the SaO2 is 97%? You're too young to be bitter.

 

[la gringa]

from a professional perspective: he could get worse before he gets better. needs at least a 23 hr obs to make sure he's improving before dc.

social situation is ALWAYS a consideration in someone's dispo... you can come up w/ many scenarios where the dispo is different if the person has insurance and good f/u vs not.

and from personal experience: pneumonia makes you feel like total crap. he doesn't need to be out in the elements nor in a shelter w/ a bunch of other people.

 

[Neuronix]

Is there a teaching service? Admit to teaching.

No teaching service? How bad does the hospital need admissions? If the place is pretty full, give the patient antibiotics from the hospital charity program and discharge.

Just kidding. Sort of.

 

[EctopicFetus]

Cough and infiltrate in a smoker who is unreliable is BS? Just because the SaO2 is 97%? You're too young to be bitter.

The point is I try to avoid admitting bs. That being said it is often unavoidable.

If outpatient is a reasonable choice I would arrange for my social worker / case manager to figure something out.

I would hold them in the ED for 4-6 hours to avoid the admission.

If I worry about them and think they would benefit from admission I would admit.

Im not bitter. I love what I do.

I have seen similar issues with insulin and I have the case manager assist with getting the patient the meds.

 

[Apollyon]

The point is I try to avoid admitting bs. That being said it is often unavoidable.

You're all over the place here. You affirmatively said that the homeless guy with the infiltrate is BS. What makes an unreliable patient with objective - not subjective - findings BS? And what is the line between BS and not, if having an infiltrate IS BS to you? If not bitter, you sound tough.

Maybe the BS that gets admitted isn't bull**** after all - may not be the highest quality, but there's some reason you bring in someone instead of streeting them.

 

[EctopicFetus]

It depends. How does the guy look, etc? My impression from the initial question is that this guy could go home.

My interpretation of the question is this. You have a homeless dude who needs antibiotics and the OP decided the guy was dischargeable.

Then the guy says he cant afford the rx. Admitting someone who doesnt have $4 is a bs admission. If he needs admit then he needs admission. If he cant go home because he doesnt have $4 to spare (regardless of reason) I make sure we resolve that rather than a $10k admission.

I give these people their first dose of antibiotics prior to dc as well.

At my shop we admit the really drunk folks, the psych folks etc. Its not tough to admit someone.

Perhaps with my above explanation you are more in agreement with me.

 

[Apollyon]

It depends. How does the guy look, etc? My impression from the initial question is that this guy could go home.

My interpretation of the question is this. You have a homeless dude who needs antibiotics and the OP decided the guy was dischargeable.

Then the guy says he cant afford the rx. Admitting someone who doesnt have $4 is a bs admission. If he needs admit then he needs admission. If he cant go home because he doesnt have $4 to spare (regardless of reason) I make sure we resolve that rather than a $10k admission.

I give these people their first dose of antibiotics prior to dc as well.

At my shop we admit the really drunk folks, the psych folks etc. Its not tough to admit someone.

Perhaps with my above explanation you are more in agreement with me.

You are more clear now. As I work overnights and don't have SW at night, and I give the first dose of ABX also, I would either obs the guy (so that he gets the meds in the AM, then the boot), or just boot him out with quite clear instructions to return.

As the OP is in an area where the indigent are rife, I am not sure how I would work it.

 

[la gringa]

Ectopic -

I hope my next job allows me the flexibility to keep people 4-6 hrs to avoid admission... my last director was obsessed w/ LOS. I even had PA's coming to me to admit drunks solely b/c it would adversely affect LOS. Knew of docs who did huge workups for 37 yo women w/ interscapular pain that was clearly musculoskeletal... b/c it was easier to do than to actually talk to and examine the patient.

This is part of what is so wrong w/ our system, and with some jobs - they want you to be perfect at everything, all at once. IMHO, you gotta pick something to sacrifice out of being a good diagnostician, satisfying patients, throughput, and LOS. I'll sacrifice LOS any day as long as I'm being a good doc, my patients get good bedside care, and people who are sick are being seen promptly. Some pts need time to prove that they're ok... ok getting off my soapbox!

 

[deleted109597]

from a professional perspective: he could get worse before he gets better. needs at least a 23 hr obs to make sure he's improving before dc.

Lots of things could get worse before getting better. Not all of them need obs. Besides, the whole point of discharge instructions is to let people know the reason to come back. In fact, people without PMDs often return to the ED better, because those with doctors that aren't getting better think "
well, I'll just go see my doctor" who send them back.

social situation is ALWAYS a consideration in someone's dispo... you can come up w/ many scenarios where the dispo is different if the person has insurance and good f/u vs not.

Sure, chest pain is one of them. But only because they can't get the followup tests. People who can get outpatient stress tests can frequently go home.
Homeless people still have the followup issue with hospital discharge too, unless you're advocating that we admit them until they are completely well.

and from personal experience: pneumonia makes you feel like total crap. he doesn't need to be out in the elements nor in a shelter w/ a bunch of other people.

So then you admit people with the flu? Because that makes you feel like crap too. Absolutely if they meet some admission criteria then admit the pna patients. But there are limits. Diverticulitis, hyperglycemia, hypertension, all of them could be admitted, some need to be admitted. Nobody is making a hard and fast rule here.

 

[emrox]

If I would otherwise d/c this person and the main thing giving me pause is the inability to fill the med, I call pharmacy and ask them to tube up an Rx and add it to their ED bill. Admittedly, the patient isn't going to pay it, butIi agree it is not worth hospitalizing and spending more if they look well and I want to send them home, even if they are homeless, etc. This ensures they leave the ED with an antibiotic in hand.

I do this a few times a year when I really want to make sure someone gets a medication and i have never had a problem. I call the pharmacist who is there and talk to them personally. It is nice that I work in a hospital who has a 24/7 pharmacist/pharmacy coverage, I know this is not the case everywhere- although you could make the argument to watch them overnight or whatever until they can get their meds in the morning, if debating admission.

 

[Flopotomist]

I think we are getting sidetracked by the details of the particular example (which is impossible to answer without further information on history, exam findings etc).

If the question is "Given a homeless person with a diagnosis X that can be treated safely as an outpatient with medication Y, but who cannot pay $4, what do you do?" Then the answer is discharge in my opinion.

If the patient can prioritize $4 for cigarettes instead of his medication, then he has a lack of good decision making skills, not a lack of resources.

 

[EctopicFetus]

You are more clear now. As I work overnights and don't have SW at night, and I give the first dose of ABX also, I would either obs the guy (so that he gets the meds in the AM, then the boot), or just boot him out with quite clear instructions to return.

As the OP is in an area where the indigent are rife, I am not sure how I would work it.

Apollyon, I work overnights only as well. We have SW/CM until 2am and someone else gets here by 7am. I would hold them until we had a safe way to dispo them. I also would not be beyond giving up the $4 and calling in the Rx to the drugstore around the corner and documenting I did all this. I cant help people who dont want to be helped.

 

[Apollyon]

Apollyon, I work overnights only as well. We have SW/CM until 2am and someone else gets here by 7am. I would hold them until we had a safe way to dispo them. I also would not be beyond giving up the $4 and calling in the Rx to the drugstore around the corner and documenting I did all this. I cant help people who dont want to be helped.

Only once have I ever given money out of my own pocket, and that was $2 for bus fare. That was because a nurse had given $20 out of her pocket for a cab for a patient.

I never had a SW in the day when I worked days, and I haven't worked a day in almost a year.

 

[EctopicFetus]

I must be lucky. They are nice and help dispo challenging patients for us. We have both SW and case managers in our ED. I will say I have only give money out of my pocket once. $5.. These situations arent that common in my ED. most people if they cant afford their meds wont tell you and FWIW most of the homeless here have medicaid which also means their rx is free.

 

[docB]

I think we are getting sidetracked by the details of the particular example (which is impossible to answer without further information on history, exam findings etc).

If the question is "Given a homeless person with a diagnosis X that can be treated safely as an outpatient with medication Y, but who cannot pay $4, what do you do?" Then the answer is discharge in my opinion.

If the patient can prioritize $4 for cigarettes instead of his medication, then he has a lack of good decision making skills, not a lack of resources.

That is the crux of the situation I was trying to evoke. I didn't think of the smoking part as a huge tangent because a lot of my patients are in the smoke when they can group and the fact that they are smokers doesn't really mean they have any cash at that particular moment.

I don't know what the "right" answer is here. I've gone both ways and my reasons are not always discernible even to me. But it is a bigger and bigger issue for us. I have to make this decision (d/c with dubious follow up or admit due to dubious follow up) more than I have to decide between Integrillin and Plavix.

 

[TrumpetDoc]

I'll tell ya what happens at my place:
I check on a lot of my admitted patients on the next shift just to see what's happening, just a computer biopsy for imaging lab results, etc.
What happens with most of the admits as eluded to above (not really sick but a follow up issue) I that they are discharged as soon as the dose of IV Abx "I started" in the dept is finished with Rx for Abx.
I have done both, just as DocB mentioned above.
I try to be as good a clinician as I can. If they "look sick" and I don't mean unstable vitals, etc...those are easy. I mean, you just know they are not well or not gonna be well. If they look sick, I put them in.
If on the fence, I will give IV dose in dept, Rx and ED recheck sometimes (as much a it pains my colleagues when they have to see them again


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[logos]

A lot of homeless are alcoholics, and are susceptible to MDR bacterial pneumoniae (including Klebsiella).

If there's an infiltrate, I almost always admit them for big gun antibiotics.

Agree. We discharge very few patients with pneumonia. Our population generally fits this description.

 

[anonymousEM]

Free doxycycline at the grocery store +/- bus ticket to go get it. I'm in the hospitalist will d/c in the morning camp as well. If looks sick but no abnl vitals ED obs unit overnight?