Case Management Approach to Homelessness

Homelessness continues to be a compliance issue.

Homelessness is a population health crisis. Doing nothing is not an option. Hospitals following existing law and best practices in population health management, within the confines of limits on resources, can make a difference. To truly address homelessness will require political will, as well as committing community, state, and federal resources.

In many regards, following the law entails much dancing in place for hospitals lacking any local resources. The California Hospital Association (CHA) admits as much. Hopefully, we can give patients a better chance of health self-management success, providing direction and assistance with filling and using prescribed medications as well as making connections with both primary care and mental health providers. These are already population health management best practices. Providing transportation, for example, does nothing in this regard but divert money better spent elsewhere. Buying medications is a financially onerous requirement best met by the states, with all their buying power.

A separate homeless policy and procedure is required. 42 CFR 482.43, CA HSC 1262.5, and SB 1152 practically writes your policy and procedure for you.

A lot of handwringing is going on about the applicability of SB 1152. There is some controversy over what patients are covered. The words “discharged patients” lead some (not supported in law) to include any hospital encounter, including ED and possibly even other OP encounters. The law applied to the broad outpatient setting will bankrupt all but the best-funded systems and facilities.

First, SB 1152 is simply an addition to the California Health and Safety Code (HSC) 1262.5. HSC 1262.5 applies only to hospital inpatients. Before the bill’s final draft was sent to the Assembly floor, the CHA negotiated some concessions, though it was not very successful. Instead, the CHA came away asserting “legislative intent” in applying SB 1152 broadly.

First, legislative intent is for the courts to decide, not risk-averse CHA lawyers. CHA says that during negotiations, the bill’s protagonists wanted to include ED visits. However, this was not part of Assembly or Senate debate, nor in any legislative summary. If the author of SB 1152 wanted the law to apply to outpatients, the entirety of 1262.5 would have to be repealed and a new law put in place.

Last week the Healthcare Association of Southern California (HASC) and the Los Angeles County District Attorney’s Office sponsored a symposium in L.A. on homeless discharges. A lawyer familiar with healthcare disagreed with CHA on the language of HSC 1262.5; SB 1152 is applicable to inpatients, they said. To do otherwise was said to be potentially disastrous to throughput and financial ability to provide care.

That said, consider what is doable in the ED setting. Just consider two things: as best as can be done with what is available and remember the legal definition of “homeless.” All that will have to wait for the next article. In the ED it is possible that immunizations for diseases common to the homeless be offered. A meal is easy to provide. Have a “clean out your closet day” and there may be the ability to provide weather-appropriate clothing. It’s not hard to put together a resource guide for homeless people. All this can be done without an elaborate discharge planning interview and costly social worker (SW) time. So far, my CFO is funding this. More, not so much.

SB 1152 is bad law: an unfunded yet costly mandate placed on a single industry that appears punitive, not helpful. Enforcing existing law as part of accreditation and licensure makes more sense.

Finally, I need to thank fellow case managers, social workers, and directors at several Inland Empire hospitals. This smart, experienced, and proactive group organized by the leadership of Hospital Association of Southern California – Inland Empire (HASC-IE) organized the Homeless Discharge Collaborative, whereby we are working on a unified, regional approach to SB 1152. Combining of talent is the best hope for designing a plan that is affordable and functional. No matter where you are in California, even if only two or three hospitals combine forces, do it. You will be glad you did.

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