Ricky Frew isn’t blaming anybody for his situation. He’s perfectly content to hang out on the streets of downtown Corvallis, drinking with his friends and sleeping wherever the night finds him.
But it’s no way to recover from surgery.
Frew, 58, was admitted to the emergency room at Good Samaritan Regional Medical Center July 7 with an old leg fracture that hadn’t healed properly. A doctor inserted a metal plate and six screws to knit the bones back together, bandaged and splinted the leg and told Frew to stay off it for six to eight weeks.
The same day, the hospital discharged Frew with vouchers for cab fare and one night in a downtown motel. A local nonprofit got him a wheelchair and a few more motel vouchers.
On the night of July 9, Frew was back at the Corvallis hospital. His incision had bled all over the motel’s carpet and sheets. The manager told him not to come back.
“My stitches come loose,” Frew said. “(Blood) was coming out the back of my cast. It was all red down in there. I knew something was wrong.”
This time he got some fresh stitches, some medicine to help his blood coagulate and a cab ride to the Signs of Victory shelter in Albany. He spent a few nights there before migrating back to Corvallis and the streets he calls home.
Julie Manning, a vice president with the hospital’s parent company, Samaritan Health Services, believes Good Sam and its discharge planners handled the situation responsibly.
“One of our social workers got involved and made a number of calls on his behalf to try to find a safe place for him to be,” Manning told the Gazette-Times.
“Based on the resources available for this person in that circumstance, that seemed to be the best option.”
The discharge dilemma
For people like Frew, the options in Corvallis are limited.
Community Outreach Inc. operates a 70-bed shelter and frequently accepts homeless patients being discharged from Good Samaritan, both from the general population and the psychiatric ward. It also has a clinic staffed with volunteer doctors and stocked with donated medications (Samaritan supplies a large share of both).
“I can’t think of a time when someone who’s been medically fragile has been turned away from here,” said Rich Donovan, the nonprofit’s executive director.
But Community Outreach also operates rehabilitation programs for drug and alcohol addiction, and it has one ironclad rule: The shelter won’t accept anyone who hasn’t been sober for at least five days.
That rules Frew out.
“We don’t do detox. It’s dangerous,” Donovan said, because people fighting a long-term alcohol addiction can go into violent seizures.
“The bugaboo is if you have somebody who’s just hell-bent on drinking after they’ve had surgery, nobody knows what to do with that population.”
For a few months each winter, local volunteers operate an “all-comers” shelter for homeless men, sober or otherwise. But it closes during the day and has no medical facilities.
The First Christian Church downtown serves free meals to those in need and hosts a daytime drop-in center for the homeless, but it’s not set up to be a shelter.
Nevertheless, the church’s pastor says, there have been at least three cases where homeless patients left Good Samaritan in taxicabs and were delivered to First Christian.
“They were discharged from the hospital and brought here and left on our doorstep,” the Rev. John Evans said. “There probably have been others who were left in other places downtown.”
Manning said she couldn’t comment on those claims without knowing the details. But she did say that Good Sam can’t keep patients indefinitely and that “the larger community” has a role to play in providing for the needs of homeless patients.
“We’re a hospital. We care for people in an inpatient setting, and we provide outpatient services,” she said. “When it is no longer medically necessary for a patient to be in the hospital, that’s when we begin to move into transitioning them to (someplace else).”
Evans acknowledged that Samaritan faces a difficult dilemma, caught between the need to free up beds for paying patients and accepting after-care responsibility for charity cases no one else wants to take.
“It is clearly wrong that people who are unable to care for themselves are discharged without anyplace for them to go,” Evans said. “That’s not entirely the hospital’s fault. It has to do with our health care system and the way we view people at the lower end of the social scale.”
The federal Emergency Medical Treatment and Labor Act requires all hospitals that accept Medicare dollars to treat anyone with an emergency medical condition, whether that individual can pay or not.
“Anyone who comes through the emergency room, we have a responsibility to stabilize them,” said Andy Van Pelt, communications director for the Oregon Association of Hospitals and Health Systems.
Last year, Van Pelt said, Oregon hospitals provided more than half a billion dollars’ worth of charity care for indigent patients.
Samaritan Health Services gave away $8.3 million in charity care throughout its five-hospital network in 2008, including $3.9 million at Good Sam.
But just where does the hospital’s responsibility to care for those patients end? At discharge? Or does it continue throughout their recovery? And who should pay for that continuing care?
Those questions came into sharp focus in 2006, when the city of Los Angeles took legal action against a number of area hospitals for dumping homeless patients in the city’s Skid Row district. In response, the state passed a law requiring hospitals to improve their discharge procedures, but that didn’t completely resolve the situation.
“One of the problems was that there aren’t enough beds to discharge these patients to,” said Linda Rodriguez of Homeless Health Care Los Angeles, noting that Los Angeles has roughly 81,000 homeless people but only about 5,000 shelter beds.
Most homeless shelters, she adds, are not equipped to take care of people with medical needs, especially if those needs are complicated by drug or alcohol dependency.
“In a lot of ways, hospitals are put in a bind in being able to find an adequate place to place people — which doesn’t absolve them from responsibility,” Rodriguez said.
In the wake of the Los Angeles scandal, some California hospitals have opted to keep homeless patients until their recovery is complete rather than risk charges of dumping.
That can be expensive. But Nan Roman, president of the National Alliance to End Homelessness, argues it can be far less spendy than the cost of repeat emergency room visits by people who get sick again after returning to the streets too soon.
“If people don’t recover, they just keep coming back,” Roman said. “That’s a cost we all bear.”
A novel approach
It’s a nationwide issue, one that hospitals and homeless advocates have been grappling with for years.
“It’s actually a very big problem,” said Laurel Weir, policy director of the National Law Center on Homelessness and Poverty.
“Hospitals are not sure what to do, and they’re not getting support from the local government or the state government,” she added. “The most effective solutions we’ve seen so far are broader partnerships between hospitals, local governments and social service organizations.”
One promising development to emerge in recent years is an approach known as medical respite care. The idea is to provide temporary housing and low-cost medical care to homeless people who aren’t sick enough to be in the hospital but are too fragile to return to the street.
“People are discharged pretty quickly these days from the hospital to the home, where they can recuperate,” said John Lozier of the National Health Care for the Homeless Council, a Nashville, Tenn., nonprofit that promotes the idea of respite care. “But without a home, you don’t have the things one comes to expect that one needs to recuperate.”
There are about 40 such programs around the country, Lozier said, including one run by Central City Concern in Portland.
“They have sprouted up independently with encouragement from each other and from our organization,” he said. “It’s a widely perceived need.”
A handful are freestanding programs, but the majority are collaborative efforts that take a variety of forms. Some are housed in homeless shelters or combine motel vouchers with visiting clinicians, while others involve arrangements with nursing homes, assisted-living facilities or treatment centers.
A 2006 study published in the American Journal of Public Health found that respite care programs resulted in a significant dropoff in expensive emergency room treatment. Compared to patients who did not receive respite care, those who did averaged five fewer inpatient days and more than a third fewer emergency room visits over the next year.
“The trick is, like everything else, getting it funded,” Lozier said. “But in a lot of places, hospitals are beginning to understand it’s in their self-interest to provide the resources for these kinds of places.”
‘There’s always more’
Like other communities around the country, Corvallis is involved in developing a 10-year plan to end homelessness, an effort led by Benton County. The draft version of the county’s plan covers a lot of ground, including the availability of health care for the homeless.
Manning, who serves on the committee developing the plan, is hopeful it will help mend some of the holes in the social safety net.
“Would it be nice if there were additional options? Absolutely,” she said.
“And as part of this community’s work around the 10-year plan to end homelessness, these are some of the very questions being addressed: What can we as a community do to address this?
“And there’s always more we can do.”
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