Equity is a principle that has long been discussed and fought for within the U.S. healthcare system. Ensuring that all individuals have equal access to quality care is at the core of every hospital’s mission. What hospitals have found is that putting equity into practice can at times be a challenging task. Many different groups have often felt the sting of systemic inequity within the medical system.
THE IMPACT OF INEQUITY
Homeless individuals are at particular risk of facing systemic inequity. This group of individuals often presents unique and difficult challenges for hospital staff engaged in treatment. Lack of access to essential resources such as social support, consistent medical care, and shelter create significant barriers to care transitions. These barriers, coupled with the stigma and biases that many believe about the homeless, leave this group particularly vulnerable. These factors, along with homeless individuals’ environmental stressors, make discharge planning difficult for both social workers and case managers. Addressing systemic inequity issues often requires facilities to take an honest and unflinching look at the cultural and systemic gaps that perpetuate inequity.
UCI MEDICAL CENTER’S RESPONSE
At UCI Medical Center (UCIMC), we are taking a proactive approach to address care issues for homeless individuals who come through our doors. We have done this by creating a multisystem strategy known as The Homeless Project. This project uses data, education and community outreach to identify areas where we can improve our homeless patients’ experience and long-term outcomes. Our project also identifies areas where the hospital needs to improve and has helped increase the staff’s accountability in working directly with homeless patients. We are taking a critical look at ourselves and how hospital systems may be contributing to inequity. Although this process can at times be painful and disappointing, it is necessary. An honest assessment of ourselves allows us to dismantle systems that no longer work for all of our patients and enables us to build new systems that provide improved equity and dignity to all patients who need medical services.
California is struggling with an increasing homeless population. The uptick in overall homelessness across the state has had a massive effect on our healthcare systems. It has also spotlighted the barriers that homeless individuals experience when they seek out medical services. In 2019, California enacted SB 1152, which requires all hospitals in California to have a written discharge planning policy and specific documentation surrounding homeless patients. Hospitals are required to identify and maintain a log of homeless patients, identify the destinations that homeless patients have been discharged to, and have standardized written discharge procedures regarding coordination of care and appropriate homeless patient discharge. SB 1152 strengthens advocacy for the homeless and confronts the inequity faced by the ever-growing homeless population in California. A report conducted by the Legislative Analyst’s Office (LAO) of California indicated that California currently houses 151,000 residents considered homeless. Currently, in Orange County, it is estimated that 6,860 individuals are homeless. The realization that Orange County has one of the largest homeless populations in Southern California often conflicts with the image that most people have when thinking of “The OC.” Many associate Orange County with wealth and affluence, mostly thanks to reality television and film, but the truth remains that Orange County is home to Disneyland and beaches and a homeless epidemic. In 2019, UCI Medical Center released a Community Health Needs Assessment that identified homelessness as an issue affecting the hospital and the greater community of Orange County. This report identified the need for the hospital to take action and increase resources and access to care for this population of individuals.
CHALLENGES & OPPORTUNITIES
The staff of UCIMC is all too familiar with the challenges of treating homeless patients and assisting them with accessing resources. Many of the patients seen in the ER and throughout the hospital are chronically unsheltered, have comorbid substance use and mental health disorders and little to no social support. The changing state standards for homeless care have led many hospitals to re-evaluate the care received by unhoused individuals. It has also required increased collaboration between hospital workers, particularly case managers and social workers responsible for providing resources and facilitating safe and manageable discharge plans for a population who are likely to struggle after discharge. Currently, UCIMC uses the Homeless Project to create a multi-pronged approach to addressing the inequities faced by our homeless patients.
The first step of this approach is to collect and interpret data surrounding this population. The hospital is specifically focusing on areas surrounding discharge and access to resources. UCIMC is compiling this data into a monthly report so that staff can identify gaps in service and address these issues in real time. This Homeless Report is a monthly collection of data focusing primarily on discharge compliance. We look at several areas of discharge that are important for the homeless community. These areas include: (1) providing resources to community organizations such as food banks, shelters and low-cost clinics; (2) making sure that patients have medications in hand at the time of discharge; and (3) charting the destinations to which patients will go after leaving the UCIMC.
Performing a monthly analysis of the various areas of care surrounding our homeless patients provides valuable information. It allows the hospital to see if specific resources are being under- or overutilized. It helps to bolster accountability among staff to provide a safe and comprehensive discharge plan which considers patients’ needs. It assists staff educators in constructing targeted education plans that acknowledge areas where case managers, social workers and RNs excel and aid with areas that need improvement. It generates increased collaboration across disciplines by opening discourse into treatment teams’ common complications when trying to assist unhoused patients with discharge and resources. When backed by credible data analysis, this discourse helps UCIMC identify structural barriers both within the hospital and in the greater community, which prevent homeless individuals from accessing resources and adopting problem-solving strategies to work around these barriers.
WE ARE PART OF A LARGER COMMUNITY
Hospitals can often become a microcosm of what is going on in greater society. At this point, Orange County has a widening wealth disparity. This social determinant has a significant impact on the patient population we care for. Many patients face the same limited access to resources in hospitals that they do in the outside world. This may include feeling rushed through treatment due to limited or no insurance. It can also include patients struggling to complete follow-up appointments and after-care due to lack of transportation or funds to continue treatment. This often creates a situation where homeless individuals cycle in and out of the emergency room to obtain treatment, which adds pressure to an already overwrought system. This activity can lead to frustration by hospital staff and management, who view these “frequent flyers” as burdens on the system. These implicit biases can be exhibited by our demeanor or tone of voice when dealing with unsheltered people. Understandably, hospitals cannot be expected to solve all issues of inequity faced by vulnerable patients, but they can look at current structures and see what needs to be updated.
UCIMC takes the lead from the state of California and uses stipulations outlined by the homeless discharge law as a jumping-off point to enact new policies concerning homeless patients. These policies have run the gamut from clarifying the definition of homelessness to standardizing discharge protocol and adding staff to work with and advocate for homeless patients. These modifications combined with the data collection that monitors our efforts’ efficacy have been vital in addressing the social disparities faced by indigent patients. It also assists with providing clarification and assistance to the case management and social work teams. These teams often have multiple issues to address when helping homeless patients. Something as simple as knowing whether a person is unsheltered or has temporary shelter and family support can assist with triaging patients according to their needs. Bringing on staff such as homeless advocates or homeless liaisons can help overwhelmed social workers and case managers. These staff members can help assist their team members with providing placement and connecting patients with resources.
EDUCATION & TRAINING
Another avenue that UCIMC has felt is essential when addressing issues regarding inequity has been education. As noted above and over time, staff in any work environment can begin to develop biases toward specific groups. These biases result from negative experiences and a lack of understanding. Working with the homeless population can be challenging. Many homeless patients distrust hospitals because they feel they have been let down in the past. These individuals also have high frequencies of substance use and mental health disorders, leading to more aggressive behavior toward staff. For social workers and case managers, these patients can often be challenging to place, and resources can be scarce, which leads to frustration. Staff education and training help combat these biases and reinforce the inclusive culture that UCIMC is looking to create. Education builds a greater understanding of the patient’s situation and factors that lead to rehospitalization. At times it can be difficult to collaborate within a hospital setting due to different disciplines focusing on different goals and aspects of patient care. Education and training are useful tools in ensuring that all staff across disciplines are informed about each other. It can also encourage communication between colleagues and open discussions regarding barriers and frustrations faced by direct service workers. Training sessions can also be a great way to introduce new and useful resources to staff and evaluate how policy changes can be made more effective. At UCIMC, we have found that using targeted training based on our ongoing data analysis to produce relevant education can further assist the hospital’s goals of increasing equitable treatment for all patients.
CARING FOR ALL MEMBERS OF OUR COMMUNITY
The final step in UCIMC’s approach to ensuring more equitable treatment for homeless patients is community outreach. As stated above, the inequity faced by indigent patients is multifactorial. Meaning it does not stem from one direct cause or concern. Multiple societal factors contribute to the hardships faced by the homeless community. While hospitals cannot address every issue faced by homeless patients, connecting patients with appropriate resources can help lower overutilization of hospital services and improve health outcomes for patients. Therefore, it is crucial to be familiar with local resources such as shelters, low-income clinics or food banks. UCIMC uses the data from our Homeless Project to look at what resources are needed to assist patients with attaining these long-term health goals. We are then making an effort to acknowledge these resources, contact them and establish an ongoing relationship. Establishing these community relationships helps case managers and social workers feel connected to our local network of resources. Often staff at many of these establishments are accommodating and can connect hospital workers to other networks. They also have good insight into the gaps in resources located in the hospital’s service area. This knowledge is invaluable to social workers and case managers who are looking to help set homeless patients up with as many opportunities to thrive as possible. At UCIMC, we have carefully cultivated our relationships with our recuperative care providers and area shelters to provide resources to our homeless patients at discharge. We are also looking to build similar relationships with other providers throughout Orange County. These efforts will help have long-term effects on our indigent patients’ health and reduce hospital overutilization. Currently, homeless patients are using emergency rooms and hospital services to fill their needs. What if case managers and social workers could assist patients with filling those needs out in the community? It will be less likely that they will use hospitalization as a catch-all resource.
Addressing social inequity in medical care is a daunting task. It requires cooperation from multiple organizations both in and out of the hospital. At UCIMC, we hope that our current Homeless Project framework will guide us toward building a more socially equitable environment for all of our patients. Our goal is to ensure that any patient who walks through our doors, whether they are wealthy or homeless, can feel that our hospital provides them with the best opportunities to thrive.