Life outside the facility.

‘Stacy Jones* is discharging today.’

‘Oh, where to?’

‘The sidewalk, I suppose. I asked staff to monitor her to make sure that our wheel chair doesn’t walk out with her.’

Besides the name change, the above is a conversation that I overheard at a Skilled Nursing Facility (SNF) during a Utilization Review (UR) meeting. During UR meetings, every single resident is discussed by all different staff members representing a wide variety of services, including social workers, Resident Care Managers, therapists, Administrators, home health agents (me) and possibly more. This way, staff members who work different schedules and separate floors can all come together and discuss patient progress and next steps.

The territory I cover for work is east Portland, and this is a different demographic than I’ve dealt with before. One of the first things I noticed was how many homeless camps my commute takes me past. Some days there is someone with a sign asking for help or money or both on almost every street corner. And because of this, sometimes the patients we are assisting are homeless, and when they leave our buildings, they go back to the streets.

The conversation above might sound a little heartless, or at least it did to me the first time I heard it, but then I heard it repeated a couple times over the course of a few months. The social workers are used to this issue; it’s not something new to them like it was to me. I know our staff try and assist every patient, but sometimes people are resistant to help. Or they really don’t have any options. Some Assisted Living Facilities (ALFs) will accept residents who were previously homeless, but it’s difficult due to state requirements, and the ALFs have to make sure they’re within regulations.

For example, someone who is homeless is most likely not going to be able to afford the $4,000/month price tag that comes with ALFs, which means they will need to qualify for Medicaid and move into a Medicaid-licensed facility. These ALFs typically have wait lists for their Medicaid apartments, and the requirements for qualifying for Medicaid include seeing a Primary Care Physician (PCP) and presenting financial and health records, which could be difficult for someone with a nomadic lifestyle.

So what do with do with someone like Stacy Jones, who came to one of our SNFs from the hospital but was homeless previously? First, we try and get her as many benefits as her insurance (which fortunately she has) allows, like a nice new four-wheel walker, which the social worker was able to acquire at no cost to Stacy. Second, we work to offer her as many positive options for her future as we can think of. Would she qualify for Medicaid? Can we talk her into considering moving into a facility? Can we help her get seen by a PCP while she’s in our SNF? But as always, it’s up to the patient, and in Stacy’s case, she refused most of the assistance offered. So, as heartless as the conversation sounds, that’s Stacy’s choice, and when she discharges from our SNF she will be right back out on the streets again.