I figure this should generate some discussion
http://www.latimes.com/news/local/la-me-dumping23mar23,0,6340897.story?coll=la-home-headlines
http://www.latimes.com/news/local/la-me-dumping23mar23,0,6340897.story?coll=la-home-headlines
Discharge planning in LA
- Thread starter ERMudPhud
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ERMudPhud said:
I think what hospitals should do is if they have a healthy, homeless person ready for discharge, but nowhere to place them, to buy them a room at the Ritz-Carlton or Le Meridien for a night. Its still cheaper than keeping them in the hospital one more day. Cheaper than a law suit. The patient is happy. And most importantly, its going to make the general public notice. Whether its a honey-mooning couple who've saved for a year for their dream "night" or some rich fat cat who's never been within 10 feet of a indigient person.
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I've discharged many a drunk who was made a trauma (and therefore had all of their clothes cut off) in paper coveralls and slippers. I try to get them to call someone to get a ride, but they often won't (or the person who is called won't come, even immediately family).
Where does our responsibilty to the underserved end? I went into EM in part because I didn't ever want to consider refusing care for someone without insurance. However, I don't feel it's my responsibilty to feed, clothe and bathe people who don't want to care for themselves.
This is a good subject for discussion. Anyone who's never cared for a drunk, drug addicted homeless person who won't take their hypertensive or diabetic meds (even if you give them for free) can't understand the level of frustration they often generate. Everyone says 'that's horrible!', and cries out in indignation but they won't stop to help an unconscious drunk on the sidewalk freezing to death.
Gotta go. It's Friday night in the big house and I don't want to miss out.
Where does our responsibilty to the underserved end? I went into EM in part because I didn't ever want to consider refusing care for someone without insurance. However, I don't feel it's my responsibilty to feed, clothe and bathe people who don't want to care for themselves.
This is a good subject for discussion. Anyone who's never cared for a drunk, drug addicted homeless person who won't take their hypertensive or diabetic meds (even if you give them for free) can't understand the level of frustration they often generate. Everyone says 'that's horrible!', and cries out in indignation but they won't stop to help an unconscious drunk on the sidewalk freezing to death.
Gotta go. It's Friday night in the big house and I don't want to miss out.
I think it points out the difference in perspective between most americans who see homelessness only as a problem if they have to step over a mentally ill, intoxicated guy on the sidewalk and people who like us who are confronted by a problem without a solution every day.
America looks at that video and says, "oh my God! They took that poor old lady in her hospital gown, threw her in a cab and dumped her on the street on skid row"
I look at it and say, "Gee, they took a homeless lady who had no medical need for continued hospitalization, gave her new clothes(maybe more than she came in with) and free cab fare to a shelter"
I work in a suburban hospital in an area with plenty of homeless but no shelters. When we have someone come in to the ED whose primary problem is homelessness there is very little in the way of social services available. Sometimes all we can say is, "well you have no medical reason for hospitalization and you were homeless when you came in so I guess you are still going to be homeless when you walk out" Sometimes we can offer bus tokens and in very rare cases we can come up with a cab voucher for a ride to the homeless shelters downtown. We are actually doing much less than the hospital in LA did.
When I was in NYC we once had a homeless endstage COPD'r who knew how to work the system to block his discharge. He hung on the service for over a month. No nursing home would take him. He couldn't go to a shelter or the street because there would be no where to deliver the oxygen he needed. Finally, in desperation the hospital actually rented him a studio apartment (in manhattan
) and paid first month, last month, and deposit just so they could discharge him to an address where O2 could be delivered. I guess they figured it was cheaper than keeping him in the hospital forever and when he was evicted he might end up at a different hospital. He thwarted even this plan by dropping dead in the hospital on the day of discharge almost 2 months after he had been admitted.
America looks at that video and says, "oh my God! They took that poor old lady in her hospital gown, threw her in a cab and dumped her on the street on skid row"
I look at it and say, "Gee, they took a homeless lady who had no medical need for continued hospitalization, gave her new clothes(maybe more than she came in with) and free cab fare to a shelter"
I work in a suburban hospital in an area with plenty of homeless but no shelters. When we have someone come in to the ED whose primary problem is homelessness there is very little in the way of social services available. Sometimes all we can say is, "well you have no medical reason for hospitalization and you were homeless when you came in so I guess you are still going to be homeless when you walk out" Sometimes we can offer bus tokens and in very rare cases we can come up with a cab voucher for a ride to the homeless shelters downtown. We are actually doing much less than the hospital in LA did.
When I was in NYC we once had a homeless endstage COPD'r who knew how to work the system to block his discharge. He hung on the service for over a month. No nursing home would take him. He couldn't go to a shelter or the street because there would be no where to deliver the oxygen he needed. Finally, in desperation the hospital actually rented him a studio apartment (in manhattan
) and paid first month, last month, and deposit just so they could discharge him to an address where O2 could be delivered. I guess they figured it was cheaper than keeping him in the hospital forever and when he was evicted he might end up at a different hospital. He thwarted even this plan by dropping dead in the hospital on the day of discharge almost 2 months after he had been admitted.- Joined
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Maybe next time they can discharge the patient to the politicians homes. I mean if they are so indignant, I'm sure they wouldn't mind housing the person for the evening and spending the next day trying to find them, food, clothing, housing, smokes, etoh (to prevent the DTs), and some free medicine because they used the last of there money on the smokes! ARGHH
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King got in big trouble for allegedly "dumping" our indigent patients back on skid row.
The actual fact, is that the patients are given cab vouchers and can call a taxi for almost anywhere they want to go.
Many of the homeless shelters for L.A. are near downtown AKA "skid row". Coincidentally that's where all the crack dealers and prostitutes hang out, which is why our patients ask to be taken there.
I'm a doctor, and I have a responsibility to treat the MEDICAL complaints of my patient. I'm not a social worker, and I'm not a soup kitchen worker. I'm not going to give you free food, shelter, or clothes unless you have a medical necessity that requires admission to the hospital.
The actual fact, is that the patients are given cab vouchers and can call a taxi for almost anywhere they want to go.
Many of the homeless shelters for L.A. are near downtown AKA "skid row". Coincidentally that's where all the crack dealers and prostitutes hang out, which is why our patients ask to be taken there.
I'm a doctor, and I have a responsibility to treat the MEDICAL complaints of my patient. I'm not a social worker, and I'm not a soup kitchen worker. I'm not going to give you free food, shelter, or clothes unless you have a medical necessity that requires admission to the hospital.
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I guess this is a bit of a bump...but I don't think that is much of a problem given it also works as a post pad:
I am hoping someone who can articulately (without too much idignation or emotion) argue the other side of this will post. That is, above is the view from the hospital, but I am interested in the side of the politicians. Thank you, no more callao chicas
I am hoping someone who can articulately (without too much idignation or emotion) argue the other side of this will post. That is, above is the view from the hospital, but I am interested in the side of the politicians. Thank you, no more callao chicas
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GeneralVeers said:
I mean, fer' crap's sake, the ED isn't a homeless shelter, a soup kitchen, or the Department of Social Services even if it does sometimes seem that way. They should take the homeless patients to the offices of the LA Times and let them take care of 'em.
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Side of the politicians? It is allways beneficial for them and their next campaigns to pick an issue and then legislate something that they can then spin as a solution. In this case since the homeless were in the hospitals care and then discharged to the street it is easy for the politicians to blame the hospitals.nocallaochicas said:
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colforbinMD said:
but, as ridiculous as they might be, do the politicians offer suggestions? alternatives?
I just can't think of what else could be done.
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nocallaochicas said:
In all honesty, where are you from? Are you American? Have you ever paid ANY attention to anything political in the US - ever?
Faith in US politicians began failing in earnest in the 1960's, and gave way in the early 1970's with Watergate. Vast and major disillusionment with an economy from hell with Jimmy Carter, then the divisive nature of the Reaganocracy (if it was good for you, it was great, but, if it wasn't, it was NOT), into the Clinton years, which had some good ideas, but were foundered by failings by Clinton the man, into this tragedy/accident that is our current president, have all led to voter apathy, governmental distrust, and feelings of dissatisfaction with the government.
Some time in the past, someone (I think it was Will Rogers) said that, "anyone smart enough to make a difference is too smart to run for office". The summation of the answer to your question is no politician has, transparently, ever done anything of note that helped anyone - at all - without helping themselves FIRST and FOREMOST. Alternatives and suggestions? Good luck. The politicians don't come up with them - they solicit their constituents to, and present them to the politicians.
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It's gotten insane here in L.A. In that article they mention that the Sheriff's office has set up cameras outside missions to prevent "dumping". The hospitals continually get chastised for this practice, but I have never heard anyone make any suggestion as to what we should do differently. The inner city hospitals in L.A. are inundated with homeless people. Probably 30-40% of my patients in an average shift are homeless. If I had to do "discharge planning" on all of them, I'd only see 3-4 people per shift, which would reduce the quality of care for the others who go unseen.
Most of our indigent are crack-addicted, non-compliant, and belligerent. Where should we send them? They use crack, get in fights, and get kicked out of shelter after shelter. We can't keep them in the hospital, as we never have any beds for sick patients, must less social admissions.
Most of the hospitals give out taxi vouchers, and the patients choose where they want to go. Most of our patients will complain about anything if questioned. If you ask them who sent them to the homeless shelter, of course they will blame the hospital if there is a perceived benefit to doing so.
Very frustrating situation, and the L.A. Times has done nothing but further destabilize the situation.
Most of our indigent are crack-addicted, non-compliant, and belligerent. Where should we send them? They use crack, get in fights, and get kicked out of shelter after shelter. We can't keep them in the hospital, as we never have any beds for sick patients, must less social admissions.
Most of the hospitals give out taxi vouchers, and the patients choose where they want to go. Most of our patients will complain about anything if questioned. If you ask them who sent them to the homeless shelter, of course they will blame the hospital if there is a perceived benefit to doing so.
Very frustrating situation, and the L.A. Times has done nothing but further destabilize the situation.
GeneralVeers said:
Perhaps a somewhat toned down letter to the editor would be useful?
The segment that I saw on CNN was actually beating up on whatever bedroom city that the hospital was in for not providing their own social services.
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Apollyon said:
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We do not and will not ever truthfully know where our discharged homeless population takes the buses and taxis we give them for free. All we can do is continually discharge our patients based on good faith that they will go where they say they are going. If someone is discharged to "home" and ends up in a back alley buying heroin, that cannot be our responsibility.
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nocallaochicas said:
So you didn't answer MY question, yet can refer to me as "pedantic and egotistic/pretentious" - which stinks of disingenuity. If you are that literate, you can do your OWN search, and find out that what I've said is true - and get your own answer to your question. As for the truth of pedantry and being egotistic and pretentious, how does that apply to me? What pumps ME up in my analysis?
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NinerNiner999 said:
Wrong. The nanny-state and quasi-communistic society of LA County says that we should feed, clothe, shelter, and pay everyone from cradle to grave, regardless of their drug addictions, immigration status, criminal behavior, or lack of ability to even accept help when given.
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NinerNiner999 said:
niner ---> heroin...alleys...baltimore....COME ON YOU SURELY JEST!!!
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GeneralVeers said:
Hey man - I know how bad LA is. I saw Crash.
j/k of course...
Hopefully LA will not set the pace for the rest of the country (as California politics so eerily predicts it will)...
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basementbeastie said:niner ---> heroin...alleys...baltimore....COME ON YOU SURELY JEST!!!
No really, its true. Sometimes they even come back with Gonhorrea!
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I work at a Kaiser ER in LA currently (not for much longer thankfully). We're really under the microscope on this issue now. It takes practically an act of God to discharge a homeless patient now, regardless of how bogus the complaint is. We've got them clogging up hall and patient beds that paying customers need. This is really starting to piss me off to no end. The god damned administrators say that we can't "dump" homeless back to the streets from which they came, but they don't offer us any other solutions. Emergency care in LA County is only going to get worse and worse, with one hospital after another closing its doors until we reach a critical mass of suckitude, at which point somebody important or somebody important's daughter will die because of delays caused by ED overcrowding, at which point they'll pass some stupid law which doesn't really address the problem. Meanwhile people will continue to get delayed care and die unnecessarily.
And yes, I've just come of a particularly painful 12 hour shift at Kaiser. Just one more month, and I'm going to work for a nice suburban ER that'll pay me more than 50% than I'm making now for far fewer headaches.
p.s. I wrote this after two Sierra Nevadas on an almost empty stomach.
And yes, I've just come of a particularly painful 12 hour shift at Kaiser. Just one more month, and I'm going to work for a nice suburban ER that'll pay me more than 50% than I'm making now for far fewer headaches.
p.s. I wrote this after two Sierra Nevadas on an almost empty stomach.
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Sessamoid said:
At 0451... this reaffirms why EM can be my only choice.
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You guys just aren't trying unorthodox solutions. Just last night I was confronted with a homeless guy who wanted to room in for a few days. So I said to him "Young man, there's no need to feel down."
I said, "Young man, pick yourself off the ground."
I said, "Young man, 'cause you're in a new town
There's no need to be unhappy."
"Young man, there's a place you can go."
I said, "Young man, when you're short on your dough.
You can stay there, and I'm sure you will find
Many ways to have a good time."
"It's fun to stay at the Y-M-C-A.
It's fun to stay at the Y-M-C-A."
"They have everything for you men to enjoy,
You can hang out with all the boys."
"It's fun to stay at the Y-M-C-A.
It's fun to stay at the Y-M-C-A."
"You can get yourself cleaned, you can have a good meal,
You can do whatever you feel."
And if not the YMCA then it sounds like Kaiser will put you up indefinitely right now.
I said, "Young man, pick yourself off the ground."
I said, "Young man, 'cause you're in a new town
There's no need to be unhappy."
"Young man, there's a place you can go."
I said, "Young man, when you're short on your dough.
You can stay there, and I'm sure you will find
Many ways to have a good time."
"It's fun to stay at the Y-M-C-A.
It's fun to stay at the Y-M-C-A."
"They have everything for you men to enjoy,
You can hang out with all the boys."
"It's fun to stay at the Y-M-C-A.
It's fun to stay at the Y-M-C-A."
"You can get yourself cleaned, you can have a good meal,
You can do whatever you feel."
And if not the YMCA then it sounds like Kaiser will put you up indefinitely right now.
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docB said:
haha, I think I'll start practicing my singing.
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Sessamoid said:
I've found a stopgap measure for this. I no longer ask if patients have anywhere to go. I assume that everyone is not homeless and then discharge them. When asked if a patient has somewhere to go, I just say "I don't know".
Sometimes ignorance can be bliss.
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I address all of the medical problems of patients, self-inflicted or not. I must admit I don't spend as much time on the CHFer in HTN emergency from snorting coke, or an alcoholic with an UGIB as I do with a less-sick patient who didn't actually cause their own disease.
I do not usually address the social situation of a patient unless it involves access to necessary medical care (oxygen, followup appts, etc) or danger (abuse, etc). I can't fix their homelessness, drug addiction, etc. If they don't have a PMD I give them the number for free health care. If they are on something I recommend AA or NA.
That isn't to say I don't want to help. I am unable to help. Occasionally I can get SW involved, but most of the patients who need help don't have the mental resources or the ambition to follow through.
If they actually look like they're going to try to help themselves, I go whole hog. That includes social admissions, calling primaries and specialists to make their appointments, etc.
Be nice, be polite, do what you can...discharge. Next patient.
I do not usually address the social situation of a patient unless it involves access to necessary medical care (oxygen, followup appts, etc) or danger (abuse, etc). I can't fix their homelessness, drug addiction, etc. If they don't have a PMD I give them the number for free health care. If they are on something I recommend AA or NA.
That isn't to say I don't want to help. I am unable to help. Occasionally I can get SW involved, but most of the patients who need help don't have the mental resources or the ambition to follow through.
If they actually look like they're going to try to help themselves, I go whole hog. That includes social admissions, calling primaries and specialists to make their appointments, etc.
Be nice, be polite, do what you can...discharge. Next patient.
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beyond all hope said:
The disappointment of many of our patients when they are discharged is palapable. I believe many of them believe that all of their medical, social, and psychiatric problems can be solved at the hospital. Surely we have a magic bullet.
But theres just not that much you can do with a homeless HIV patient with PCP pneumonia except admit him, treat his presenting complaint, offer him some desulatory drug-rehab opportunity or another and send him on his way. I think modern hospitals are so big that many patients are stunned that we ask them to leave before every problem in their life is solved. Surely their is room in a place that big.
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la gringa said:
I know the feeling. When I rotated through ward medicine, it was impossible to get anyone discharged without social services finding them 1. Transportation, 2. a place to go, 3. Medical insurance/Medicare, 4. Follow-up. It was really frustrating because I'd spend several hours getting all that set up, and I knew full well that most people wouldn't take advantage of any of it.
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la gringa said:
Yeah. I wince when I hear my 28-year-old third year resident who went straight from the bosom of her family to college to medical school to Duke offering lifestyle advice to some hoary old drug addict who has been shooting heroin since the late sixties, has had more partners than Amway, and was admitted for PCP pneumonia, cocaine-induced chest pain, and looks twice his stated age.
As if he's going to slap his head, exclaim "Eureka!" and sheepishly apologize for the hash he's made of his life.
Why patronize the guy?
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Panda Bear said:
4 years of medical school programming is a hard thing to defeat. Fortunately in my case non of the med school programming "stuck" so I came out just as cynical as when I went in.
When I was a senior resident I once saw a guy for some minor work related injury. After a few minutes I realized he was one of our most notorious homeless drunks who had disappeared several months earlier. We all assumed he was dead since he was usually almost a daily visitor to the ED Somehow he had gotten himself straightened out and now had a home and a job. I looked back at the old records and discovered that on his last drunk homeless visit one of my colleagues had written "Please stop drinking or you will die" on his discharge instructions. I guess every so often it works because I tell every drunk/drug abuser I see the same thing now figuring that even if it only works once every 5-10 years that it is still worth it. (I have a secret feeling the "Please" part might be important)Panda Bear said:
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ERMudPhud said:
You're right. But I think the key is to be firm. I have a patient in my family medicine clinic who has lost weight, stopped smoking, and has dropped his HGBA1C to human levels all because he says I put the fear of God into him. He asked me how he was doing and I bluntly told him he was going to die soon, but not before he went blind and had his legs amputated.
But I think he was motivated before he saw me and I just geve him the excuse.
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There's a town called Pahrump about 60 miles west of Vegas. It is a place where many of the inhabitants have settled there because they just don't fit in well in more mainstream places (that's my best try at being diplomatic). They have no hospital there so when they get sick they just call 911 for a ride to the clinic... I mean ER. So on Saturday I get an 80 yo LOL in NAD who came in on the ambulance to ask me an improtant question:
LOL in NAD: "DocB, will you do my annual pap smear?"
Me: "No."
So her ER work up completed and her discharge paperwork in hand she askes me how she's going to get back from whence she came. I astutely referred this to the charge nurse. Eventually they were able to get some neighbor to come to pick this lady up. She was very upset that we could not just provide her with suitable transport. She really wanted to know why the ambulance couldn't just come and get her and she also opined loudly that they should have waited on her. But that's what people think, that society should get them from door to ER and back.
LOL in NAD: "DocB, will you do my annual pap smear?"
Me: "No."
So her ER work up completed and her discharge paperwork in hand she askes me how she's going to get back from whence she came. I astutely referred this to the charge nurse. Eventually they were able to get some neighbor to come to pick this lady up. She was very upset that we could not just provide her with suitable transport. She really wanted to know why the ambulance couldn't just come and get her and she also opined loudly that they should have waited on her. But that's what people think, that society should get them from door to ER and back.
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docB said:
I feel your pain, docB.
Ya gotta wonder, though, why do they think this? Because, as a society, we do everything we can to reinforce this notion that all of their woes are actually our problem and not theirs.
No home, no job, no heath care? No problem, we'll provide it for you. After a few generations, of course they expect it.
Some Democrat I am. Hrumph. Get a job, @#&hole.
One of my favorite bumperstikers says "work harder. millions on wellfare depend on you".
Man, I seem to be grumpy today. See what being awake for 30+ hours does to me? I hate call.
Take care,
Jeff
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So I had another similar situation today. A guy came in from some other little town out in the desert by ambulance the workup was brief:
Patient: "My wife threw me out of the house for sleeping with this waitress. Can I stay in the hospital for a few days?"
Me: "No."
So I go and tell the charge nurse that Room 6 wants a cab voucher which gave her the best chuckle she had had all day. Since she was in a joking mood I offered "You know I'm still an EMT and I have a pickup truck. It's not equiped but that basically constitutes an ambulance."
She didn't even look up and said, "DocB you and I both know that if I let you start driving folks out into the desert the only equipment you'll need is a shovel." Touche. Don't mess with charge nurses.
Patient: "My wife threw me out of the house for sleeping with this waitress. Can I stay in the hospital for a few days?"
Me: "No."
So I go and tell the charge nurse that Room 6 wants a cab voucher which gave her the best chuckle she had had all day. Since she was in a joking mood I offered "You know I'm still an EMT and I have a pickup truck. It's not equiped but that basically constitutes an ambulance."
She didn't even look up and said, "DocB you and I both know that if I let you start driving folks out into the desert the only equipment you'll need is a shovel." Touche. Don't mess with charge nurses.
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docB said:
Good story. I had a 60 year old homeless guy call the ambulance for quote: "No food in my stomach for 3 days". I promptly discharged him (after his courtesy CXR and EKG) without feeding him. He also took a dump on the floor on the way out.
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GeneralVeers said:
Must not have been a very substantial dump if he really hadn't eaten in 3 days!
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mikecwru said:
Some of my attendings demand "courtesy" labs or X-rays. One of our least competent attendings told one of my colleagues that no one gets discharged without "courtesy labs". They're not actually looking for anything, they just like it to appear that we've done something for the patient.
When he's on, I want to shoot myself in the head repeatedly. I have no choice but to order the BS labs. Every time I argue with him I get the lecture: "In the REAL world you'll be ordering these labs all the time to screen for things that will get you sued. You want to keep your license don't you?"
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BKN said:
But general sir. . .you don't argue with attendings!
I'll addend my previous statement. I don't argue with COMPETENT attendings. If the good attendings order something that I think is a bit wacky I'll do it without argument, because presumably they are more knowledgable than I am.
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GeneralVeers said:
One of the many things I have learned in my short time in this business: If a patient threatens to take a dump on the floor, there is a very high likelihood that he will follow through with it!
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I still have no good way to measure or evaluate this, but I'm convinced that the dispossessed and those who are shafted by one part of "the system" (welfare, unemployment, maybe even parking tickets for all I know) feel an enhanced sense of entitlement. They feel they have some recompense coming, and so they treat the ED as a part of the system they can -- honorably, justifiably, to their way of thinking -- exploit.docB said:
The problem is of course that whomever they've been screwed by, screwing us in return doesn't actually accomplish anything. But people will go to amazing lengths to assert a sense of control. I'd love it if a public education campaign could make it clearer, but I don't understand most of the issues. I just read a primer on how reimbursement works, and I want to go drink heavily.
