I met Antony when he was first admitted to the hospital with a bacterial skin infection on his leg. He was a 67-year-old man with a kind and peaceful demeanor that belied the fact that he had been living in a downtown homeless shelter for more than a year.
He spent seven days in the hospital for antibiotic treatment before being discharged back to the shelter. Three weeks later, he was readmitted with an abscess in his leg, at the site of his previous infection. It was clear that the past few weeks had taken a toll on him both physically and mentally. Antony described his experience of being discharged and then readmitted as “a rollercoaster.”
Unfortunately, it is not uncommon for homeless patients to be readmitted to the hospital within a relatively short time span. Readmission rates for the general population are already considered high; an unplanned return to the hospital creates a substantial financial burden on the health care system. However, for individuals who are homeless, readmission rates are nearly four times higher than other low-income patients.
An observational study with data from 12 U.S. academic medical centers identified preventable factors leading to readmission – many of which are evident with Antony’s story.
Poor Discharge Planning
A provider’s perception of readiness for discharge does not always correspond with the patient’s. As Antony’s and countless other cases show, physicians and discharge planners need to pay careful attention to the patient’s perspective.
Looking back at his initial discharge from hospital, Antony said:
“I was not ready to go and it was quite frustrating to have to come back. I was quite angry. I don’t want to go back [to the shelter] when I’m not really feeling better than when I came in.”
Physicians need to consider that a somewhat longer hospital stay may be necessary in light of the patient’s living situation and that careful follow-up planning and communication is essential. Although a few extra days in the hospital might seem costly, it might save patients from being readmitted in the long run. That would result in cost savings and less emotional burden on the patient.
Communication between providers and with patients needs to improve
Communication problems among physicians and between physicians and patients can lead to sub-optimal care and inadequate monitoring of a patient’s condition. Inadequate communication occurs most frequently during patient handovers, such as at the time of discharge. Antony reported such an experience of confusing communication while in hospital:
“The day before my discharge, I had a nice doctor who told me ‘You’ll stay until you get better’ and then the next day, a different doctor came and said I was ready to go. It seemed like they weren’t on the same page.”
Lack of a patient advocate
When people are admitted to the hospital, family and friends often provide help and support. They advocate for the patient, for example, by waving down a nurse or physician when care is needed, or asking questions about issues that need to be addressed when the patient is too sick to speak for him or herself. Patients who are homeless, unfortunately, often lack these advocates, and this may increase the risk of inadequate treatment, and ultimately lead to readmission. Reflecting on this experience, Antony said,
“I was thinking if my friend or family was here, they could’ve said ‘He’s not ready to leave yet.’ For people like me who don’t have support, we need an advocate.”
We recommend hospitals that serve homeless and other marginalized patients to consider creating a formal role for the Marginalized Patient Advocate. This patient advocate can speak on behalf of disadvantaged patients who do not have someone to help them. Ensuring that these patients’ needs are met may reduce the risk of readmission, especially for those who lack formal or informal support systems.
Unsafe and unhygienic shelter Conditions
The living situation to which patients are being discharged may seem obvious but it’s too often ignored. Shelters are sometimes unhygienic, usually crowded, and almost always stressful places.
People staying at shelters are at constant risk of having their belongings, including medications, stolen. At many shelters, residents are required to leave in the morning and walk the streets until they are allowed to return in the evening. The instability, stress, health outbreaks and lack of staff available for appropriate wound care makes a shelter one of the worst possible places for discharge – yet patients are discharged from hospital to shelters all the time. As Antony described:
“There’s lots of problems with bugs and scabies in the shelter. I started scratching my foot and then strep got in because there was a strep outbreak in the shelter. I got treated with oral antibiotics in the shelter but it just kept coming back.”
Respite programs for homeless individuals who are too ill or unstable to return to the street or to a shelter should be expanded in Canada. These programs have started in approximately 50 locales in the U.S. and have been shown to reduce readmission rates.
We must note that homelessness is a systemic problem whereby the health care system bears a substantial burden. At the root of this issue is a lack of affordable housing, which is a major social determinant of health. We urge policymakers to invest in supportive housing as it may not only reduce the prevalence of homelessness, but also reduce the risk of readmission to hospital.
At the same time, health care providers should do everything they can to improve the quality of care for patients who are homeless and devote particular time and attention to factors that contribute to readmission.
By reducing readmission rates – especially for homeless patients – substantial numbers of unnecessary hospitalizations can be prevented, thereby improving patient outcomes and reducing health care spending (due to more advanced health problems, homeless patients cost on average $2,500 more than housed patients per hospitalization).
It is time that health care providers and policymakers alike work together to tackle this issue – for the sake of people like Antony.