By Brian Davis
Managed care gets bad reviews from customers for placing a dollar figure on health care and worrying about the bottom line before the life line, but how does managed care impact the homeless?
Imagine having a breast removed, and being told to change the bandages in a shelter. Imagine walking around with AIDS looking for a shelter that will allow for all day bed rest. Imagine being turned away from a stay in the hospital with only a one day prescription because your condition was not serious enough for admittance and then being turned away from the shelters because your condition was too serious to risk infecting the other customers. This is managed care for homeless people.
Those who exist on the streets and the shelters cannot recuperate in their homes. They do not have the luxury of bed rest, and cannot expect help from shelter staff to change dressings or assist with other bodily functions for those barely able to walk.
Officials at Harbor Light shelter said, ‘They just want people out. They use shelters as a dumping ground. They are releasing a lot of people too early without a lot of medicine.”
A Harbor Light staff person reported that one client fell down the stairs and had to go to the hospital. Instead of putting a rod in his elbow and attempting to reconstruct the bone, the doctors decided that it would be cheaper to remove the bone so the individual had only half the strength in his arm.
Another person at Harbor Light was burnt. He received a minimum level of care at the hospital and was released with some Tylenol aspirin. And before the law was changed, a woman delivered cesarean and was released within twenty four hours. This staff member who did not want to give his name said, “Homeless people are not treated the same. It is not like it is on TV.”
A Harbor Light official reported that social workers often lie about a patients condition to get them out of the hospital. He said, “We don’t even deal with St. Luke’s. They aren’t straight with you.”
Officials from St.Luke’s said, “Harbor Light is accepting referrals from us. In February, we placed someone in Harbor Light for Detox and we put someone in there in the last two weeks. They may question us more, but it would not be accurate to say that they are not accepting our referrals.
West Side Catholic, a women’s shelter, said that they are usually full so they have a hard time accepting customers from area hospitals. They had a recent woman who had breast cancer and needed a room to recover. They allowed the woman to stay two weeks and she got to know shelter staff and residents as her only family. Aggie Hoskins, Director of West Side Catholic, said, “It is a real dilemma for shelters and services on the whole. We are not designed to assist people who cannot take care of themselves.”
Both St. Vincent Hospital and St. Luke‘s confirmed that there are no special rules with regard to admitting or keeping ho0meless people for extended stays. A spokesperson from St. Vincent emphasized that each person is treated individually, but there are no special rules for homeless people. “Our mission is to take care of people no matter their ability to pay. We do not extend the hospital stay for homeless people.”
St. Luke’s said we do not differentiate between someone who is homeless and someone who is not homeless. A St. Luke’s official said homeless people can be referred to residential care or a skilled nursing facility, but they cannot stay at St. Luke’s. They confirmed that there are stringent guidelines for being admitted to the hospital at the emergency room, and
housing does not play a role.
Because there are no special protocols for homeless people organizations like Cleveland Health Care for the homeless get people with full-blown AIDS who are discharged and told to medicate and take care of themselves through CHCH. They saw an individual two days out of surgery who was told to keep their bandages clean on the streets.
Gerald Hilinski, the nurse practitioner at CHCH, said that managed care is a serious problem that is forcing shelters to provide health care to people with serious illnesses. He characterized the problem as increasing over the past year. He says that without the proper recovery time people have a relapse and are back in the hospital or at the clinics operated by CHCH. There is also the possibility of developing an infection, which could lead to losing a body part or death.
In Cleveland, there is one public hospital left, Metrohealth Medical Facility. Despite their public mission they do not offer any longer stays or better care for homeless people. Hilinski said, “They don’t operate any different than the other hospitals.” After one week of trying no one from Metrohealth returned repeated requests for comment.
Hilinski did not fault the doctors who he said were as “frustrated as the rest of us.” He laid the blame squarely on the managed care system. He said, “I think it would be optimum to allow homeless people to be exempt from the rules. It is my opinion that managed care drove this process. Let people providing health care do their job.
There was a proposal on the table to provide care to homeless people who are discharged from a hospital and who need some health care The Sisters of Charity decided to put together a program called Joseph”s Home to serve homeless refugees of the Managed Care system. They surveyed homeless service providers in the area with twenty-five organizations responding. All twenty-five said that a shelter for homeless people to recover was necessary. The Services reported between two and sixty people needing an augmented health care shelter each month.
Sister Joan Gallagher of the Sisters of Charity said that they found that a lot of homeless people were not admitted to the hospital, but were given medication and told to come back later. She said, “The shelters could not handle these people especially those with respiratory problems because they were contagious.
When asked how this situation developed, Gallagher laid the blame squarely on the changes in the Managed Care system. Gallagher said, “In the past, the hospitals would admit these individuals. They had more funds to cover it. They cannot handle these situations (with homeless people). Hospitals these days really have no plans for people without homes.
The project sought federal funds, but was turned down due to the limited use of Housing Funds. The Sisters intend to put the project on hold for one year, and refocus the program to be more of a traditional facility to accommodate Federal requirements.
Hilinski summed it up by saying, “It is my belief that we are not saving any money (under managed care). We are paying twice, three times because they didn’t fix the condition in the first place.”
Copyright for the Homeless Grapevine Cleveland Ohio Issue 27 May 1998