When Did the Hospital Become a Pathway to Housing?

In my recent hospital travels, involving working with frontline case management staff, we completed an initial assessment and intervened with a patient who provides one example of the significant issues hospitals are seeing when it comes to social admissions. The patient was a 47-year-old quadriplegic male admitted with back pain. The patient had a significant trauma approximately five years ago from a diving incident that completely turned his life upside down and landed him dependent on family and governmental support.

The patient was admitted to the hospital under outpatient with observation services while his “back pain” was being evaluated. In reviewing the hospitalist history and physical examination (H&P) we learned that the patient was “hoping to go to skilled care until he could move into his brother’s house.” This is a red flag, from a case management standpoint, and warranted further investigation with the patient. 

During our conversation with this likable gentleman, we saw his predicament: his one brother, who is a paid caregiver, can no longer easily care for him due to his own age and debility. The patient’s other brother is now willing to take him in and care for him, but his home will need significant remodeling to handle the patient’s handicap needs. The patient believed that if he “got into the hospital,” he could either get greater caregiver support or go to skilled nursing while the home repairs were completed. When asking the patient why he believed the hospital would solve this problem, he stated that this is what he remembered his previous rehab physician telling him. 

This is one example of the systemic issues in our communities: there is a failure to intervene with patients, resulting in an unnecessary hospitalization, meaning that their social determinant, most often housing, can be solved in the hospital. Patients are sitting in beds in hospitals across the country, as we speak, because they are homeless and lack access to supportive shelters, because their home situation is inadequate, or because they require a pathway to long-term nursing care facilities. Time and time again, the hospital has become the answer to these determinants, rather than the community-based social services. 

Physicians’ heartstrings are being pulled with patients being admitted to the hospital, because their social situation is “not safe,” skewing the boundaries and definitions of medical necessity. This is by far the most expensive means to a necessary result to help these individuals, and unfortunately, the payor system does not support the need. In our fee-for-service world, this patient scenario will likely result in denied days for observation from his managed Medicaid plan. The hospital case manager and physician will then deal with the ethical dilemma of discharging this patient and many others back to their subpar conditions. 

This patient does not belong in a skilled nursing facility (SNF), nor does he have medical necessity for such placement. The easy answer would be to try anyways, but instead, the case manager and I spun our wheels trying to creatively find social-service and volunteer agencies to help this patient, while also trying to find his long-term care case manager. Our efforts were an attempt to get his caregiver hours increased and educate the patient on the realities of his health insurance and unnecessary hospitalization. 

This topic will continue to be an area of conversation by MedLearn Media, with Dr. Hirsch’s upcoming webcast regarding payment and compliance for the “Outpatient in a Bed” designation, as well as future webcast topics focusing on social complexities and methods for hospitals to handle such patients.

The initial answer involves figuring out how we can prevent the regular response of “go to the hospital” – and if the patient arrives nonetheless, how we delineate social complexities with unideal determinants from medical necessity.

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.