An Rx for disaster

MICHAEL R. COUSINEAU is associate professor of research and the director of the Center for Community Health Studies at the USC Keck School of Medicine.

THE CITY OF Los Angeles has sued several local hospitals for allegedly dumping their discharged homeless patients on the streets of or on the doorsteps of shelters in skid row. Surveillance cameras were purportedly mounted on top of shelters and missions to film the incidents. One publicized story told of a woman who was taken to skid row against her will after being discharged from a Kaiser Permanente facility. Hers and other accounts have evoked public sympathy and emboldened public officials and law enforcement personnel to decry the practice of patient dumping as immoral, unethical and even criminal.

Although troubling, the Kaiser Permanente case should highlight the underlying problems of the continuing shortage of mental-health treatment programs, medical services and housing for the homeless, as well as the chronic deficiency in shelter beds. As such, the suit seems a distraction from the failures of government and private institutions to provide for the homeless. At worst, it turns healthcare professionals willing to treat homeless patients into villains.

We have known for at least 20 years that homeless people are more likely to have serious mental and health problems as a result of living on the streets. Women, especially, are all too often victims of rape, robbery and assaults. It seems almost scandalous that the public officials who criticize health providers for allegedly dumping patients are the same ones who have done little to improve access to healthcare for the homeless. When unable to obtain care, homeless patients find their way to an emergency room, where they inevitably encounter long lines. Many get frustrated and leave before seeing a doctor. And there are no surveillance cameras to capture these untreated patients returning to skid row.

No doubt it is the responsibility of hospitals to provide the best healthcare possible to all their patients. But the complex health and psychiatric problems of the homeless are difficult to manage under the best of circumstances. It is simply wrong to hold hospitals accountable for assuring that patients get services that are unavailable. Discharge planners spend hours trying to find a place for homeless patients who are well enough to leave the hospital. But if all the shelters are full, or there are no facilities to accommodate a person who requires some level of after-care, the hospital faces a dilemma: If it decides to keep the patient longer, and the state or health insurer doesn't authorize additional payment, the hospital must cover those costs.

To achieve good clinical outcomes for homeless patients, the city and the county must ensure that hospitals and doctors have a safe and medically appropriate place to send such people once they are discharged. The absence of any such facilities makes the criminal investigation of the hospitals especially troubling, because the city of Los Angeles, not hospitals, is in the position to provide adequate housing for the homeless before and after they are in the hospital, and Los Angeles County is in the position to provide support services.

There is no simple way out of this dilemma. A group of nonprofit service providers, along with the county Department of Mental Health, have proposed the construction of supportive housing that would include a medical clinic, mental health services and dental care. But it's being held up because the city and county can't agree on its location and scope. Yet it is precisely these kinds of solutions that the city and the county, along with local businesses, private partners and homeless advocates, should be pursuing. A similar project in San Francisco reduced hospital emergency room visits and unnecessary hospital admissions. But while L.A. public officials spar, homeless patients continue to suffer needlessly on our streets, and healthcare institutions struggle to provide effective and humane care.

But there are short-term solutions. Some private foundations recently expanded a respite-care program in skid row to 42 beds, where recently hospitalized homeless patients can receive up to 90 days of medical support and housing to help them recuperate from an illness or injury. The county also has allocated nearly $20 million to pay for housing alternatives for patients discharged from hospitals and jails, but the city still has no plan to do the same. If the city and county combined funds to expand respite-care centers in skid row and replicate them elsewhere, hospital discharge planners would have a much-needed boost in resources.

Outrage about alleged dumping of discharged homeless patients in skid row should be directed not at healthcare providers but at policymakers at all levels of government who let the scourge of homelessness continue. Homeless advocates are equally remiss in allowing policy discussions to overlook the systemic problems that underlie homelessness. Coming up with long-term solutions to the problem won't be easy. But elected leaders and service providers should concentrate on ways to expand affordable and supportive housing for homeless patients, improve their access to care and treat their drug- and alcohol-abuse problems and mental illness.

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