Leaving before Discharge from a Homeless Medical Respite Program: Predisposing Factors and Impact on Selected Outcomes Joanna Bauer, Alice Moughamian, Joyce Viloria, Michelle Schneidermann Journal of Health Care for the Poor and Underserved, Volume 23, Number 3, August 2012, pp. 1092-1105 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2012.0118
For additional information about this article https://muse.jhu.edu/article/481735
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Original Paper
Leaving before Discharge from a Homeless Medical Respite Program: Predisposing Factors and Impact on Selected Outcomes Joanna Bauer, MPH Alice Moughamian, RN, CNS Joyce Viloria, MD Michelle Schneidermann, MD Abstract: Background. Medical Respite addresses care needs of homeless patients post- hospital discharge and is linked to reduced rehospitalization compared with standard discharge. However, outcomes may differ for Respite patients who exit before completing post-acute treatment and discharge plans. Methods. Using administrative data from a San Francisco Medical Respite center (2007–2010), this retrospective study compares patient characteristics, post-Respite connections to community services, and likelihood of rehospitalization within 90 days of Respite exit between patients who choose to leave before discharge and all other Respite patients (logistic regression, odds ratio). Findings. Of 860 encounters, 31% ended when patient chose to leave before discharge. Female gender (OR 1.65), living on the street immediately prior to Respite (OR 1.36) and substance use (OR 1.55) were associated with increased risk of leaving early. Patients who left early were more likely than others to decline referrals to services and more likely to be re-admitted within 90 days. Key words: Homeless, hospitalization, medical respite, aftercare.
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educing preventable hospital readmission—especially among frequent users—is important for health care systems. New health care reform legislation further places attention on readmissions, and provides incentives for systems of care that examine and demonstrate innovative and effective practices that reduce hospitalization among frequent users.1 Homeless populations suffer disproportionately high rates of chronic and infectious disease, mental illness, and substance use-related health problems.2–6 Homelessness is consistently associated with longer and repeated hospital stays 7–9 and homeless individuals are disproportionately represented among frequent users of hospital care.10 Among
Joanna Bauer and Alice Moughamian are affiliated with the San Francisco Department of Public Health, Department of Housing and Urban Health; Joyce Viloria and Michelle Schneidermann are with the Department of Medicine, San Francisco General Hospital, UCSF School of Medicine. Please address correspondence to Joanna Bauer, MPH; San Francisco Department of Public Health, Department of Housing and Urban Health; 1171 Mission St.; San Francisco, CA 94103; [email protected]. © Meharry Medical College
Journal of Health Care for the Poor and Underserved 23 (2012): 1092–1105.
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people who are homeless, competing priorities,11 barriers to routine medical care,12 and challenges with medication adherence13–14 all represent risk factors for hospital use. In addition, post-discharge patients often return to environments that are sub-optimal for healing, and may face difficulty with medication management, routine follow-up, and adherence to after-care plans that increase likelihood of re-hospitalization. Medical Respite programs provide an alternative to street discharge for homeless patients. The Medical Respite model addresses specific needs of homeless patients by providing temporary housing and post-acute medical care for those who are too ill or frail to recover from a physical illness or injury on the streets, but are not ill enough to be in a hospital.15,16 To date, over 57 Medical Respite programs have been established in U.S. cities.17 While the capacity and level of service provision varies among these programs, they uniformly provide a safe and clean environment appropriate for healing and access to nursing and medical staff to assist patients with routine aftercare, wound care and medication support.15 Effective strategies to reduce re-hospitalization include consistent patient education and seamless transition to community medical care.18–20 At Medical Respite these strategies are tailored to serve homeless patients who may not have a history of successful engagement with community based services. A recent review of Respite models across the U.S. noted that Medical Respite presents a critical window to engage homeless patients and make connections to community based medical care, social services and housing that can help patients continue successful transition.17 Among homeless populations, routine primary care, substance abuse treatment, and entrance into supported housing programs have all been shown to have independent, positive effects on likelihood of hospitalization.11,20–22 The San Francisco Medical Respite is a 45-bed residential facility in downtown San Francisco, established in 2007 by the San Francisco Department of Public Health Housing and Urban Health Department (SFDPH). San Francisco Medical Respite accepts patient referrals from the city’s public hospital, San Francisco General Hospital (SFGH), the Veteran’s Administration Hospital, University of California and San Francisco (UCSF) Medical Center, and seven private community hospitals. As in other cities, homeless patients in San Francisco are disproportionately represented among high users of medical services, and SFGH staff estimate that up to 20% of inpatients are homeless on any given night. Due to the high number of homeless inpatients, Respite referrals are often triaged by both referring providers and Medical Respite staff. As a result, Respite serves patients who are among the most medically complicated, who are typically triply diagnosed (medical, psychiatric, and substance use) and who have multiple chronic medical conditions. Onsite Respite medical staff (seven days a week and 24 hours on call) include registered and advance practice nurses, physicians and physician assistants, and medical assistants who, as a team, provide urgent and intermediate care, health education services, and referrals to primary and specialty care in the community. Community health workers provide support services as well as case management, under the supervision of social workers. Social workers individually assess all patients, and assist patients obtaining government issued identification, income benefits (such as Social Security Disability Insurance)
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and medical coverage (Medi-Cal or Medicaid). Where appropriate, social workers also assist patients in applying for supported housing (SFDPH also administers a supported housing program: Direct Access to Housing). Respite staff continue to follow up with patients throughout their medical treatment and discharge planning to make appropriate referrals and assist with patient appointments as needed. Discharge plans are reviewed by multi-disciplinary teams with an eye toward ensuring both that patients are medically ready for discharge and that referrals and follow up services are sufficiently in place to promote success in the community. Prior evaluations of Medical Respite programs in Boston and Chicago have found that patients discharged from hospitals to Respite are significantly less likely to be re-hospitalized than those discharged to self care.23,24 Using intent to treat analysis, these studies use as the treatment population all patients who enter Respite regardless of whether or not they complete medical treatment plans. However, one study noted that outcomes may be different for patients who leave before completing treatment.24 Leaving against medical advice (AMA) from a hospital ward significantly raises risks of re-hospitalization.25 One recent study found patients who left AMA from a hospital were seven times more likely to be re-hospitalized within 15 days, often for the same diagnosis.26 While Respite provides a lower level of care for patients who are already medically ready for hospital discharge, many of them are still medically complex and at high risk of re-hospitalization. Patients who leave Respite against medical advice (AMA) or become absent without leave (AWOL) may return to unsafe environments and patients who leave without announcement may not have the benefit of basic exit instructions for ongoing care. In addition, these patients may not have the same smooth transition to ongoing primary care or housing interventions that are typically part of a well coordinated discharge planning process. To our knowledge, this is the first study to examine patients who leave early from a Medical Respite. We determine the proportion of patients who leave against medical advice (AMA) or become absent without leave (AWOL) from an urban Medical Respite program in a city with a large homeless population. The goal of this analysis is to identify patient characteristics associated with leaving early and test any significant differences in key outcomes among patients who leave before discharge—including connection to community supports and likelihood of emergency room or hospital admission within 90 days of Respite exit.
Methods This is a retrospective cohort study comparing patients who leave AMA and AWOL to all other patients at a large urban Medical Respite program in its first three years of operation (2007–2010). All Respite encounters with an intake and exit date before July 1, 2010 were included and all encounters are unique (individual patients with multiple Respite stays are included as unique encounters). Study design was approved by University of California at San Francisco Committee on Human Research Ethics (CHR). Views expressed herein do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.
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Data and measures. Data on length of stay in Respite, diagnoses, patient characteristics and community referrals were obtained from centralized electronic patient records maintained by the SFDPH in a secure online database (the Coordinated Case Management System [CCMS]). Coordinated Case Management System information is collected by Respite staff as part of routine intake procedure. Medical charts, referring provider and staff assessment are used to determine medical diagnosis and Axis I diagnosis. Substance abuse is determined through patient chart and assessment where possible, but also may be self-reported. Other characteristics, such as utilization of medical and mental health services, prior housing situation and income are patient self-report either at Respite admission or hospital admission. Length of stay at Respite, medical and community referrals and exit disposition are also recorded in charts and transferred to CCMS at patient exit. Exit disposition includes: discharge to self, discharge due to rule violation, discharge to treatment program or higher level of care (including hospital), exit against medical advice (AMA) or absent without leave (AWOL). The population of interest includes patients with discharge disposition of AMA or AWOL. Against medical advice patients announce departure and exit before completing either medical treatment or discharge plans. Absent without leave patients are patients who do not announce departure but are absent from Respite for over 48 hours without alerting staff and are not located in any local hospitals or jails. The comparison group includes all other discharge dispositions. Patients discharged to self-care have been deemed ready by multi-disciplinary staff after completing both medical treatment and discharge plans. The comparison group also includes patients discharged to other facilities and patients discharged early due to rule violation, as the purpose of this study is to examine patients who choose to leave. Data about patient readmission to San Francisco General Hospital was obtained from the Lifetime Clinical Record (LCR), a secure electronic database maintained by the SFDPH to track all encounters at SFGH and SFDPH clinics. Patient name, date of birth and medical record number was used to match records to the LCR by Respite clinicians. Lifetime Clinical Record uses separate coding for ER and inpatient hospital admissions. Analysis. Data were combined and abstracted before analysis. All analysis was performed using STATA version 9 (StataCorp., 2005, Stata Statistical Software: Release 9 [College Station, TX: StataCorp LP]). Logistical regression and chi-squared tests for association were used to test for independent associations between patient characteristics at entry and leaving AMA/AWOL (unadjusted odds ratios, 95% confidence intervals). Characteristics independently associated with leaving AMA or AWOL (p value .05) were included in second multivariate logistical regression model to test for strength of association. Logistical regression (chi squared, odds ratio) was used to compare likelihood of accepting or declining referrals to new community services. Comparisons were made among a subset of patients whose CCMS data indicated that they were not engaged in services at entry and demonstrated some need for each service. For medical referrals, a subset of patients without primary care at Respite entry was used; for mental health referrals, we looked at a subset of patients with Axis I diagnoses and no mental health
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provider at entry, and substance treatment was measured using a subset of patients who were substance users. Two separate analyses examined hospital admission among patients with different exit dispositions. In the first, likelihood of readmission to ER and hospital by each exit disposition was examined, using discharge to self as a referent group. A second multivariate model compared patients leaving AMA/AWOL to all other patients, adjusting for characteristics associated with both exposure (AMA/AWOL) and outcome (hospitalization).
Results There were 860 complete Respite patient encounters between March 2007 and August 2010. The majority of Respite patients were male (80%), over 50 years of age (60%). The majority (78%) of Respite patients were referred from SFGH; 7% were referred from the VA hospital and 16% from other private hospitals including UCSF (5%). Patients were most commonly referred for wound care, post-assault or post-operative care while a minority were referred for chronic or infectious disease. The majority of patients are triply diagnosed with medical, mental health and substance use diagnoses. Patients tended to enter Respite without connection to community medical care (65% had no primary care provider), income benefits (79%) or identification (75%). At the point of hospital intake, the majority of patients reported living on the street or in a vehicle (59%) or in an emergency shelter (18%). The most common exit disposition was discharge to self-care (45%), followed by AWOL (22%), higher level of care/hospital (13%), AMA (9%) and rule violation (9%) (Table 3). Of 276 patients (31%) who left AMA or AWOL, 22% completed a medical treatment plan before exiting, compared with 77% of the comparison group. The overall mean length of stay at Respite for all patients was 34 days. The mean length of stay for AMA and AWOL patients was five days (not shown), and these patients were significantly more likely to leave within one week of entering Respite. Factors associated with leaving AMA or AWOL. Female patients and patients under 50 years were significantly more likely to leave AMA or AWOL than male patients and older patients (Table 1). Living outside before entering Respite, having no income and arriving without identification were also significant predisposing factors for leaving AMA or AWOL. Substance use was also significantly associated with leaving AWOL, although separate analyses (not shown) indicate that substance use was not significantly associated with leaving AMA (p value .05). Patients with an Axis 1 diagnosis were significantly less likely to leave AMA or AWOL, whether or not they were substance users (dually diagnosed)—patients with substance use and a mental health diagnosis were not at any increased risk of leaving early (Table 1). In multivariate analysis female gender (OR 1.76, p value .01), self-report of living on the street or vehicle (OR 1.44, p value .01) and having no income or benefit source (OR 1.94, p value .01) were all associated with increased likelihood of leaving AMA or AWOL. Patients who identified (self report or medical record) as current substance users (alcohol or illicit substances) were significantly more likely to leave AMA or AWOL (Table 2).
207 69 125 110 104 28 10 54 24 34 25 22 14 80 16 64
Male
Female**
Age under 50 years*
Race/ethnicity Caucasian African American Latino/a API/Filipino
Common referral diagnosis Wound Care Assault Orthopedic Condition Post Operative Care Pneumonia Cancer
Axis I diagnosis, all* Axis I diagnosis, no substance use** Axis I and substance use*
N
29 20 26
20 9 12 9 8 5
40 38 20 4
45
25
75
%
Left before discharge (AMA or AWOL) (n5276)
250 260 212
101 36 68 63 48 29
251 195 78 13
218
98
479
N
Discharged (n5584)
43 33 35
17 6 12 11 8 5
43 33 13 2
37
17
82
%
CHARACTERISTICS AT ENTRY OF PATIENTS AT MEDICAL RESPITE (2007–2010)
Table 1.
0.55 0.49 0.65
1.16 1.45 1.06 0.82 0.97 0.69
0.88 1.20 1.05 1.68
1.39
1.65
0.66
(0.81, 1.68) (0.85, 2.48) (0.69, 1.65) (0.51, 1.34) (0.57, 1.64) (0.34, 1.21)
(0.66, 1.18) (0.90, 1.62) (0.97, 1.14) (0.74, 3.80)
(1.04, 1.86)
(1.17, 2.34)
(0.47, 0.93)
95% CI
(0.40, .074) (0.28, .087) (0.47, 0.91) (Continued on p. 1098)
Odds Ratio
177 41 40 1 3 191 161 235 224 147
Circumstances before entry Living outside, encampment, car* Sheltered Unstably housed (living with friends) Hospital* Renting room or apartment
Resources and services at entry No primary care provider Uninsured (no med coverage) No income at entry** No ID at entry** No services connections reported
*P value .05 **P value .01 AMA 5 Against Medical Advise AWOL 5 Absent Without Leave CI 5 Confidence Interval
216 130 104 61 152
N
69 58 85 81 53
64 15 14 .4 1
78 47 38 22 55
%
Left before discharge (AMA or AWOL) (n5276)
Substance use, any** Alcohol Cocaine Opiates Substance use, no Axis I**
Table 1. (continued)
379 353 441 424 318
332 110 92 14 18
408 257 184 112 223
N
Discharged (n5584)
65 60 76 73 54
57 18 16 2 3
70 44 32 19 38
%
1.22 .92 1.86 1.63 .95
1.36 0.75 0.91 0.15 0.35
1.55 1.13 1.31 1.20 1.98
Odds Ratio
(.89, 1.65) (.79, 1.23) (1.27, .2.72) (1.14, 2.31) (.72, 1.27)
(1.00, 1.82) (0.51, 1.10) (0.61, 1.35) (0.03, 0.92) (0.10, 1.18)
(1.11, 2.17) (0.85, 1.51) (0.98, 1.77) (0.84, 1.69) (1.49, 2.65)
95% CI
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Table 2. CHARACTERISTICS ASSOCIATED WITH LEAVING BEFORE DISCHARGE (AMA/AWOL) MULTIVARIATE REGRESSION MODEL Patient characteristics Female* Under 50 years old No income at entry reported** No identification at entry Substance use without Axis I diagnosis** Living outside prior to hospitalization and Respite**
Odds Ratio
p value
1.76 1.44 2.04 1.62 1.94 1.44
0.00 0.07 0.00 0.16 0.00 0.01
*P value .05 **P value .01 AMA 5 Against Medical Advise AWOL 5 Absent Without Leave
Community based health care and housing referrals. Patients who left AMA or AWOL were significantly less likely to be connected to community based medical, mental health and substance treatment services by Respite staff than other patients (Table 3). Separate analyses (not shown) indicated that patients leaving early were no less likely to be offered service referrals than other patients when adjusting for length of stay. However, patients who left AMA or AWOL were more likely to decline service referrals than other patients (Table 3). There was a considerable disparity around uptake of medical services; among patients who entered without an established primary care provider, 29% of patients who left early declined primary care referrals compared to 5% of other patients (Table 3). Another significant disparity was in connection to supported housing: 4% of patients who left early started a supported housing application, compared with 29% of other patients. Emergency room and hospital admission within 90 days. In all, 41% of patients were admitted to the emergency room within 90 days of leave Respite and 20% were admitted to the hospital (not shown). Table 4 shows likelihood of emergency room and hospital readmission within 90 days of Respite exit among all exit dispositions compared to discharge to self (reference). Patients who left AMA were significantly more likely to be admitted to emergency room (OR 1.78) but not hospitalization, while patients who left AWOL were significantly more likely to be admitted to both emergency room (OR 2.11) or hospital (OR 2.98) compared with patients who completed medical and discharge plans before being discharged to self. Increased risk of readmission was not significant when adjusting for substance use (Table 4). Independent tests (not shown) also found that substance use and living outside before entering Respite were associated with both greater likelihood of leaving AMA/AWOL and readmission within 90 days. Using a multivariate logistical regression model that
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Table 3. SELECTED OUTCOMES FOR PATIENTS AT MEDICAL RESPITE Patients who left before discharge (n5276)
Completed medical treatment plan* Length of stay in Respite Less than 7 days** More than 30 days* Referrals by Respite staff Primary medical provider** Mental health provider* Substance abuse treatment** Supported housing (applied)** Referrals declined by patients Primary medical provider** Mental health provider** Substance abuse treatment**
Discharged patients (n5584)
N
%
N
%
Odds Ratio
95% CI
60
22
450
77
0.08
(0.06, 0.12)
112 40
41 14
48 305
8 53
7.63 0.16
(5.22, 11.15) (0.11, 0.23)
79 10 10 11
41 14 5 4
273 65 44 164
72 29 12 29
0.27 0.30 0.40 0.11
(0.19, 0.39) (0.15, 0.59) (0.19, 0.81) (0.06, 0.20)
33 21 33
29 68 77
13 34 60
5 34 58
3.08 4.00 2.42
(4.40, 17.5) (1.70, 9.48) (1.07, 5.42)
*P value .05 **P value .01 CI 5 Confidence Interval
included substance use and leaving AMA/AWOL, the likelihood of readmission among AMA/AWOL was not significantly higher than for other patients (Table 4).
Discussion Effective strategies to reduce rehospitalization include patient engagement, education and ongoing aftercare support from health care providers.18,19 Medical Respite programs employ these strategies as a bridge for high needs patients to aftercare services, and discharge planning is a critical component of this model. A study of Respite in Chicago examined hospitalization within 90 days of Respite exit found a similar proportion of patient readmission (20%) than was found here.23 As hypothesized, there were significant differences by exit disposition. Excluding patients discharged to a higher level of care, patients at highest risk of rehospitalization were those who were discharged due to rule violation, followed by those leaving AMA or AWOL. Given the high proportion of patients who leave Respite early, and differences in
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Table 4. LIKELIHOOD OF ADMISSION TO PUBLIC EMERGENCY ROOM OR INPATIENT HOSPITAL WITHIN 90 DAYS OF MEDICAL RESPITE EXIT, BY EXIT DISPOSITION Emergency room admission Patient exit disposition Discharge to self (referent) Against Medical Advice (AMA) Absent without leave (AWOL)* Discharge for rule violation** Discharge to treatment program or medical facility (excluding hospital) Discharge to hospital** AMA or AWOLa
Hospital admission
Odds Ratio
95% CI
Odds Ratio
95% CI
1.0 1.78* 2.11** 3.21** 0.98
— (1.05, 3.01) (1.47, 3.04) (1.95, 5.28) (0.45, 2.12)
1.0 1.59 2.98** 2.83** 1.97
— (0.72, 3.53) (1.78, 4.98) (1.45, 5.52) (0.63, 6.16)
3.29** 1.35
(1.91, 5.68) (0.99, 1.84)
7.63** 1.32
(4.00, 14.53) (0.87, 2.00)
*P value .05 **P value .01 a Referent group is all discharged patients, adjusted for current substance use and living on the street before Respite entry. CI 5 Confidence Interval
length of stay, connection to community based medical provider and other supports and rate of rehospitalization, AMA and AWOL patients are an important population of concern. For providers, identifying patients at risk of leaving early can be a critical first step in developing interventions to serve them better. Several associations found here indicate that early exit from Respite may be linked to differences in engagement, motivation, and trust among patients. For example, patients who had been living in a shelter were more likely to stay, while immediately history of living outside was associated with early exit. These patients may have felt constrained by Respite structure, but also may have been following a pattern of behavior that—for many reasons—resulted in discomfort or disinterest in engaging with service providers. Similarly, patients who left Respite early were also significantly more likely to decline other services when offered: these included primary care, case management, supportive housing, and even income benefits. Women in this study were significantly more likely to leave Respite before discharge completion than male patients. Given the prevalence of victimization among homeless women and the association of trauma to fear and social withdrawal27–28 re-traumatization from lack of privacy, sense of scrutiny, or power dynamics may all contribute to earlier exit among female patients. Experience with other facility based treatment indicates
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that gender specific treatment models or women-only spaces may enhance retention outcomes. Research on treatment models for homeless substance users, suggests that distrust is a stronger barrier to engagement among women: drug treatment programs that are successful are those that address women’s victimization and create safe space.29,30 Research also consistently finds higher retention among programs that are women-only, rather than mixed gendered.29 Although male and female patients are housed in different parts of the Respite facility, real or perceived risk of victimization may impact female patients’ early departure. Additional research should explore how trauma impacts female patients’ experience at Respite. Substance use was the strongest risk factor for early Respite exit. Although patients can leave the facility, SFDPH Medical Respite requires that patients abstain from using substances in the facility. While factors that range from feelings of constraint to distrust may impact early departure, these patients may also leave early due to desire to use.29 Notably, in this study, dually diagnosed individuals were more likely to finish treatment than patients without a mental health diagnosis. The reasons that dually diagnosed Respite patients were more likely to stay are unclear. It is possible that these patients perceived a greater need for ongoing care; it is also possible that medication management provided at Respite enhances compliance which may positively affect retention. The link between substance use and frequent hospital use is well documented in other literature.31 In this analysis, substance using individuals were significantly more likely to be rehospitalized than other patients, even when adjusting for discharge disposition. This further indicates that completing treatment may not have the same benefit for substance using patients than other patients. Moreover, it should be noted that even patients who completed Respite often declined referrals for substance abuse treatment. While outcomes are not uniform across all Respite patients, this study also showed the important role that Medical Respite can fill in linking patients to ongoing community based care and housing programs. Over half of all patients reported no community based service connections at intake and many left with critical linkages in place. Respite provided opportunities for engagement with many patients: over half were connected to ongoing primary care and supportive housing processes were started for over one fifth of all patients. Further research should examine models and methods to enhance retention for Respite patients, given the benefits of completing care. Limitations. There were several limitations to this study. This was a retrospective study relying on medical and program records. Rates of psychiatric comorbidities and substance use may have been underestimated, leading to incorrect assumptions about completion of treatment. Additionally, this study was conducted in one model of Respite care with a limited, though relatively large, patient population. Though there are limited data to characterize different homeless populations, some published data suggest that San Francisco’s homeless population has a particularly high prevalence of intravenous drug use.32 Rates of IVDU were not captured for this study and thus could not be analyzed. It is possible that other Respite programs might encounter different outcomes. Looking specifically at patients who choose to leave compared with all other patients, there may be differences within the comparison population that affected outcomes.
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Patients discharged due to rule incidents may have been less likely to engage and may have left before treatment completion if they had been allowed to stay. Patients discharged to a higher level of care may have been less likely to receive services than patients who were discharged to self-care. No qualitative data was collected about patients’ decisions to leave early (e.g., through exit interviews). Although data included a variety of factors previously associated with leaving AMA, a number of other factors may influence AMA in ways we could not determine. For example, perceiving oneself as healed, having obligations outside of the facility, distrust, or—as has been discussed—desire for more control or simply feeling constrained may all contribute to early departure. These more subtle motivations cannot be determined by our analysis. Additional qualitative research or exit interviews may be helpful in providing a more complex and complete picture of individuals’ motivations. Using SFDPH records to measure readmission only includes patients who were admitted to SFGH emergency room or inpatient ward post-Respite discharge. San Francisco General Hospital is the city’s only public hospital and serves a large proportion of the homeless, and 78% of patients entering Respite were referred from SFGH. However, there are other community-based hospitals where patients may have been treated post-Respite: patients picked up by an ambulance may be taken to the closest community hospital, rather than SFGH. While it should be noted that SFGH is often the first place homeless or indigent patients are taken for emergency room care, inability to track admission to other hospitals is a limitation here. Conclusion. This is the first study to examine patients who choose to leave Medical Respite AMA or AWOL. Between 2007–2010, 31% of Respite encounters ended when patients left AMA or AWOL, while 45% were discharged to self after completing medical and discharge plans. Female patients, patients who had been living on the street (rather than shelter) and patients without public benefits were all significantly more likely to leave before discharge. In addition, patients who were substance abusers without an Axis 1 diagnosis were significantly more likely to leave AMA or AWOL, while patients with dual diagnosis (substance abuse and Axis 1) were more likely to finish treatment. Patients who left AMA and AWOL stayed significantly fewer days in Respite and were significantly less likely to complete treatment plans than other patients. Further, while Respite helped establish ongoing medical support and housing for many patients, AMA and AWOL patients were significantly less likely to have these services in place at exit. While rate of readmission overall was similar to previous research on the impact of Respite, leaving early was associated with increased risk of rehospitalization—though not significant when adjusting for substance use. Given the high rate of patients leaving before treatment completion and differences in key outcomes by exit disposition, further research should continue to examine how to better identify, retain and serve patients at high risk of leaving Medical Respite early.
Acknowledgments The authors wish to acknowledge Maria X. Martinez at the San Francisco Department of Public Health and Carol Chapman for their work on the CCMS database.
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Notes 1. Orszag PR, Emanuel EJ. Health care reform and cost control. N Engl J Med. 2010 Aug 12;363(7):601–3. Epub 2010 Jun 16. 2. Sachs-Ericsson N, Wise E, Debrody CP, et al. Health problems and service utilization in the homeless. J Health Care Poor Underserved. 1999 Nov;10(4):443–52. 3. Levy BD, O’Connell JJ. Health care for homeless persons. N Engl J Med. 2004 Jun 3;350(23):2329–32. 4. Zlotnick C, Zerger S. Survey findings on characteristics and health status of patients treated by federally funded health care for the homeless programs. Health Soc Care Community. 2009 Feb;17(1):18–26. Epub 2008 Jun 17. 5. Cousineau M. Health status and access to health services by residents of urban encampments in Los Angeles. J Health Care Poor Underserved. 1997 Feb;8(1):70–82. 6. Baggett T, O’Connell JJ, Singer D, et al. The unmet health care needs of homeless adults: a national study. AJPH. 2010 July;100(7):1326. 7. Kushel M, Vittingoff E, Haas J. Factors associated with the health care utilization of homeless persons. JAMA. 2001 Jan 10;285(2):200–6. 8. Salit SA, Kuhn EM, Hartz AJ, et al. Hospitalization costs associated with homelessness in New York City. N Engl J Med. 1998 Jun 11;338(24):1734–40. 9. Rosenheck R, Seibyl CL. Homelessness: health service use and related costs. Medical Care. 1998 Aug;36(8):1256–64. 10. Raven MC, Billings JC, Goldfrank LR, et al. Medicaid patients at high risk for frequent hospital admission real time identification and remediable risks. J Urb Health. 2009 Mar;86(2):230–41. Epub 2008 Dec 12. 11. Gelberg L, Gallagher TC, Anderson RM, et al. Competing priorities as a barrier to medical care among homeless in Los Angeles. Am J Pub Health. 1997 Feb;87(2):217–20. 12. Gallagher TC, Andersen RM, Koegel P, et al. Determinants of regular source of care among homeless adults in Los Angeles. Med Care. 1997 Aug;35(8):814–30. 13. Kidder DP, Wilitski RJ, Campsmith ML, et al. Health status, health care use, medication use and medication adherence among homeless and housed people living with HIV/AIDS. Am J Pub Health. 2007 Dec;97(12):2238–45. Epub 2007 Oct 30. 14. Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ. 2000 Jul 25;163(2):161–5. 15. Zerger S. Medical respite care for homeless people: a growing national phenomenon. J Health Care Poor Underserved. 2009 Feb;20(1):36–41. 16. Gundlapalli A, Hanks M, Stevens SM, et al. It takes a village: a multidisciplinary model for the acute illness aftercare of individuals experiencing homelessness. J Health Care Poor Underserved. 2005 May;16(2):257–72. 17. Edgington SD, ed. Medical respite program directory: descriptions of medical respite programs in the United States and Canada. Nashville, TN: National Health Care for the Homeless Council, 2011. 18. Jack B, Veerappa KC, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009 Feb;150(3):178–87. 19. Boutwell A, Griffin F, Hwu S, et al. Effective interventions to reduce rehospitalizations: a compendium of promising interventions. Cambridge, MA: Institute for Healthcare Improvement, 2009. 20. Martinez TE, Burt MR. Impact of permanent supported housing on the use of acute health services by homeless adults. Psychiatr Serv. 2006 Jul;57(7):992–9.
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21. Culhane DP, Metraux S, Hadley TR. The impact of supportive housing for homeless people with severe mental illness on the utilization of the public health, corrections, and emergency shelter systems: the New York–New York Initiative. Housing Policy Debate. 2002;13(1):107–63. 22. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349–57. 23. Buchanan D, Doblin B, Sai T, et al. The effects of respite care for homeless patients: a cohort study. Am J Pub Health. 2006 Jul;96(7):1278–81. Epub 2006 May 30. 24. Kertesz SG, Posner MA, O’Connell JJ, et al. Post-hospital medical respite care and hospital readmission of homeless persons. J Prev Interv Community. 2009;37(2):129–42. 25. Hwang SW, Li J, Gupta R, et al. What happens to patients who leave hospital against medical advice? CMAJ. 2003 Feb 18;168(4):417–20. 26. Fiscella K, Medrum S, Barnett S. Hospital discharge against advice after myocardial infarction: deaths and readmissionas. Am J Med. 2007 Dec;120(12):1047–53. 27. Wenzel SL, Leake BD, Gelberg L. Health of homeless women with recent experience of rape. J Gen Intern Med. 2000 Apr;15(4):265–8. 28. Rokach A. Loneliness and intimate partner violence: antecedents of alienation of abused women. Soc Work Health Care. 2007;45(1):19–31. 29. Zerger S. Substance abuse treatment: what works for homeless people? A review of the literature. Washington, DC: National Health Care for the Homeless Council, 2002. 30. Watkins KE, Shaner A, Sullivan G. The role of gender in engaging the dually diagnosed in treatment. Community Ment Health J. 1999 Apr;35(2):115–26. 31. Padgett DK, Struening EL. Influence of substance abuse and mental disorders on emergency room use by homeless adults. Hosp Community Psychiatry. 1991 Aug;42(8):834–8. 32. O’Connell JJ. Premature mortality in homeless populations: a review of the literature. Washington, DC: National Health Care for the Homeless Council, 2005.
For additional information about this article https://muse.jhu.edu/article/481735
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Original Paper
Leaving before Discharge from a Homeless Medical Respite Program: Predisposing Factors and Impact on Selected Outcomes Joanna Bauer, MPH Alice Moughamian, RN, CNS Joyce Viloria, MD Michelle Schneidermann, MD Abstract: Background. Medical Respite addresses care needs of homeless patients post- hospital discharge and is linked to reduced rehospitalization compared with standard discharge. However, outcomes may differ for Respite patients who exit before completing post-acute treatment and discharge plans. Methods. Using administrative data from a San Francisco Medical Respite center (2007–2010), this retrospective study compares patient characteristics, post-Respite connections to community services, and likelihood of rehospitalization within 90 days of Respite exit between patients who choose to leave before discharge and all other Respite patients (logistic regression, odds ratio). Findings. Of 860 encounters, 31% ended when patient chose to leave before discharge. Female gender (OR 1.65), living on the street immediately prior to Respite (OR 1.36) and substance use (OR 1.55) were associated with increased risk of leaving early. Patients who left early were more likely than others to decline referrals to services and more likely to be re-admitted within 90 days. Key words: Homeless, hospitalization, medical respite, aftercare.
R
educing preventable hospital readmission—especially among frequent users—is important for health care systems. New health care reform legislation further places attention on readmissions, and provides incentives for systems of care that examine and demonstrate innovative and effective practices that reduce hospitalization among frequent users.1 Homeless populations suffer disproportionately high rates of chronic and infectious disease, mental illness, and substance use-related health problems.2–6 Homelessness is consistently associated with longer and repeated hospital stays 7–9 and homeless individuals are disproportionately represented among frequent users of hospital care.10 Among
Joanna Bauer and Alice Moughamian are affiliated with the San Francisco Department of Public Health, Department of Housing and Urban Health; Joyce Viloria and Michelle Schneidermann are with the Department of Medicine, San Francisco General Hospital, UCSF School of Medicine. Please address correspondence to Joanna Bauer, MPH; San Francisco Department of Public Health, Department of Housing and Urban Health; 1171 Mission St.; San Francisco, CA 94103; [email protected]. © Meharry Medical College
Journal of Health Care for the Poor and Underserved 23 (2012): 1092–1105.
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people who are homeless, competing priorities,11 barriers to routine medical care,12 and challenges with medication adherence13–14 all represent risk factors for hospital use. In addition, post-discharge patients often return to environments that are sub-optimal for healing, and may face difficulty with medication management, routine follow-up, and adherence to after-care plans that increase likelihood of re-hospitalization. Medical Respite programs provide an alternative to street discharge for homeless patients. The Medical Respite model addresses specific needs of homeless patients by providing temporary housing and post-acute medical care for those who are too ill or frail to recover from a physical illness or injury on the streets, but are not ill enough to be in a hospital.15,16 To date, over 57 Medical Respite programs have been established in U.S. cities.17 While the capacity and level of service provision varies among these programs, they uniformly provide a safe and clean environment appropriate for healing and access to nursing and medical staff to assist patients with routine aftercare, wound care and medication support.15 Effective strategies to reduce re-hospitalization include consistent patient education and seamless transition to community medical care.18–20 At Medical Respite these strategies are tailored to serve homeless patients who may not have a history of successful engagement with community based services. A recent review of Respite models across the U.S. noted that Medical Respite presents a critical window to engage homeless patients and make connections to community based medical care, social services and housing that can help patients continue successful transition.17 Among homeless populations, routine primary care, substance abuse treatment, and entrance into supported housing programs have all been shown to have independent, positive effects on likelihood of hospitalization.11,20–22 The San Francisco Medical Respite is a 45-bed residential facility in downtown San Francisco, established in 2007 by the San Francisco Department of Public Health Housing and Urban Health Department (SFDPH). San Francisco Medical Respite accepts patient referrals from the city’s public hospital, San Francisco General Hospital (SFGH), the Veteran’s Administration Hospital, University of California and San Francisco (UCSF) Medical Center, and seven private community hospitals. As in other cities, homeless patients in San Francisco are disproportionately represented among high users of medical services, and SFGH staff estimate that up to 20% of inpatients are homeless on any given night. Due to the high number of homeless inpatients, Respite referrals are often triaged by both referring providers and Medical Respite staff. As a result, Respite serves patients who are among the most medically complicated, who are typically triply diagnosed (medical, psychiatric, and substance use) and who have multiple chronic medical conditions. Onsite Respite medical staff (seven days a week and 24 hours on call) include registered and advance practice nurses, physicians and physician assistants, and medical assistants who, as a team, provide urgent and intermediate care, health education services, and referrals to primary and specialty care in the community. Community health workers provide support services as well as case management, under the supervision of social workers. Social workers individually assess all patients, and assist patients obtaining government issued identification, income benefits (such as Social Security Disability Insurance)
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and medical coverage (Medi-Cal or Medicaid). Where appropriate, social workers also assist patients in applying for supported housing (SFDPH also administers a supported housing program: Direct Access to Housing). Respite staff continue to follow up with patients throughout their medical treatment and discharge planning to make appropriate referrals and assist with patient appointments as needed. Discharge plans are reviewed by multi-disciplinary teams with an eye toward ensuring both that patients are medically ready for discharge and that referrals and follow up services are sufficiently in place to promote success in the community. Prior evaluations of Medical Respite programs in Boston and Chicago have found that patients discharged from hospitals to Respite are significantly less likely to be re-hospitalized than those discharged to self care.23,24 Using intent to treat analysis, these studies use as the treatment population all patients who enter Respite regardless of whether or not they complete medical treatment plans. However, one study noted that outcomes may be different for patients who leave before completing treatment.24 Leaving against medical advice (AMA) from a hospital ward significantly raises risks of re-hospitalization.25 One recent study found patients who left AMA from a hospital were seven times more likely to be re-hospitalized within 15 days, often for the same diagnosis.26 While Respite provides a lower level of care for patients who are already medically ready for hospital discharge, many of them are still medically complex and at high risk of re-hospitalization. Patients who leave Respite against medical advice (AMA) or become absent without leave (AWOL) may return to unsafe environments and patients who leave without announcement may not have the benefit of basic exit instructions for ongoing care. In addition, these patients may not have the same smooth transition to ongoing primary care or housing interventions that are typically part of a well coordinated discharge planning process. To our knowledge, this is the first study to examine patients who leave early from a Medical Respite. We determine the proportion of patients who leave against medical advice (AMA) or become absent without leave (AWOL) from an urban Medical Respite program in a city with a large homeless population. The goal of this analysis is to identify patient characteristics associated with leaving early and test any significant differences in key outcomes among patients who leave before discharge—including connection to community supports and likelihood of emergency room or hospital admission within 90 days of Respite exit.
Methods This is a retrospective cohort study comparing patients who leave AMA and AWOL to all other patients at a large urban Medical Respite program in its first three years of operation (2007–2010). All Respite encounters with an intake and exit date before July 1, 2010 were included and all encounters are unique (individual patients with multiple Respite stays are included as unique encounters). Study design was approved by University of California at San Francisco Committee on Human Research Ethics (CHR). Views expressed herein do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.
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Data and measures. Data on length of stay in Respite, diagnoses, patient characteristics and community referrals were obtained from centralized electronic patient records maintained by the SFDPH in a secure online database (the Coordinated Case Management System [CCMS]). Coordinated Case Management System information is collected by Respite staff as part of routine intake procedure. Medical charts, referring provider and staff assessment are used to determine medical diagnosis and Axis I diagnosis. Substance abuse is determined through patient chart and assessment where possible, but also may be self-reported. Other characteristics, such as utilization of medical and mental health services, prior housing situation and income are patient self-report either at Respite admission or hospital admission. Length of stay at Respite, medical and community referrals and exit disposition are also recorded in charts and transferred to CCMS at patient exit. Exit disposition includes: discharge to self, discharge due to rule violation, discharge to treatment program or higher level of care (including hospital), exit against medical advice (AMA) or absent without leave (AWOL). The population of interest includes patients with discharge disposition of AMA or AWOL. Against medical advice patients announce departure and exit before completing either medical treatment or discharge plans. Absent without leave patients are patients who do not announce departure but are absent from Respite for over 48 hours without alerting staff and are not located in any local hospitals or jails. The comparison group includes all other discharge dispositions. Patients discharged to self-care have been deemed ready by multi-disciplinary staff after completing both medical treatment and discharge plans. The comparison group also includes patients discharged to other facilities and patients discharged early due to rule violation, as the purpose of this study is to examine patients who choose to leave. Data about patient readmission to San Francisco General Hospital was obtained from the Lifetime Clinical Record (LCR), a secure electronic database maintained by the SFDPH to track all encounters at SFGH and SFDPH clinics. Patient name, date of birth and medical record number was used to match records to the LCR by Respite clinicians. Lifetime Clinical Record uses separate coding for ER and inpatient hospital admissions. Analysis. Data were combined and abstracted before analysis. All analysis was performed using STATA version 9 (StataCorp., 2005, Stata Statistical Software: Release 9 [College Station, TX: StataCorp LP]). Logistical regression and chi-squared tests for association were used to test for independent associations between patient characteristics at entry and leaving AMA/AWOL (unadjusted odds ratios, 95% confidence intervals). Characteristics independently associated with leaving AMA or AWOL (p value .05) were included in second multivariate logistical regression model to test for strength of association. Logistical regression (chi squared, odds ratio) was used to compare likelihood of accepting or declining referrals to new community services. Comparisons were made among a subset of patients whose CCMS data indicated that they were not engaged in services at entry and demonstrated some need for each service. For medical referrals, a subset of patients without primary care at Respite entry was used; for mental health referrals, we looked at a subset of patients with Axis I diagnoses and no mental health
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provider at entry, and substance treatment was measured using a subset of patients who were substance users. Two separate analyses examined hospital admission among patients with different exit dispositions. In the first, likelihood of readmission to ER and hospital by each exit disposition was examined, using discharge to self as a referent group. A second multivariate model compared patients leaving AMA/AWOL to all other patients, adjusting for characteristics associated with both exposure (AMA/AWOL) and outcome (hospitalization).
Results There were 860 complete Respite patient encounters between March 2007 and August 2010. The majority of Respite patients were male (80%), over 50 years of age (60%). The majority (78%) of Respite patients were referred from SFGH; 7% were referred from the VA hospital and 16% from other private hospitals including UCSF (5%). Patients were most commonly referred for wound care, post-assault or post-operative care while a minority were referred for chronic or infectious disease. The majority of patients are triply diagnosed with medical, mental health and substance use diagnoses. Patients tended to enter Respite without connection to community medical care (65% had no primary care provider), income benefits (79%) or identification (75%). At the point of hospital intake, the majority of patients reported living on the street or in a vehicle (59%) or in an emergency shelter (18%). The most common exit disposition was discharge to self-care (45%), followed by AWOL (22%), higher level of care/hospital (13%), AMA (9%) and rule violation (9%) (Table 3). Of 276 patients (31%) who left AMA or AWOL, 22% completed a medical treatment plan before exiting, compared with 77% of the comparison group. The overall mean length of stay at Respite for all patients was 34 days. The mean length of stay for AMA and AWOL patients was five days (not shown), and these patients were significantly more likely to leave within one week of entering Respite. Factors associated with leaving AMA or AWOL. Female patients and patients under 50 years were significantly more likely to leave AMA or AWOL than male patients and older patients (Table 1). Living outside before entering Respite, having no income and arriving without identification were also significant predisposing factors for leaving AMA or AWOL. Substance use was also significantly associated with leaving AWOL, although separate analyses (not shown) indicate that substance use was not significantly associated with leaving AMA (p value .05). Patients with an Axis 1 diagnosis were significantly less likely to leave AMA or AWOL, whether or not they were substance users (dually diagnosed)—patients with substance use and a mental health diagnosis were not at any increased risk of leaving early (Table 1). In multivariate analysis female gender (OR 1.76, p value .01), self-report of living on the street or vehicle (OR 1.44, p value .01) and having no income or benefit source (OR 1.94, p value .01) were all associated with increased likelihood of leaving AMA or AWOL. Patients who identified (self report or medical record) as current substance users (alcohol or illicit substances) were significantly more likely to leave AMA or AWOL (Table 2).
207 69 125 110 104 28 10 54 24 34 25 22 14 80 16 64
Male
Female**
Age under 50 years*
Race/ethnicity Caucasian African American Latino/a API/Filipino
Common referral diagnosis Wound Care Assault Orthopedic Condition Post Operative Care Pneumonia Cancer
Axis I diagnosis, all* Axis I diagnosis, no substance use** Axis I and substance use*
N
29 20 26
20 9 12 9 8 5
40 38 20 4
45
25
75
%
Left before discharge (AMA or AWOL) (n5276)
250 260 212
101 36 68 63 48 29
251 195 78 13
218
98
479
N
Discharged (n5584)
43 33 35
17 6 12 11 8 5
43 33 13 2
37
17
82
%
CHARACTERISTICS AT ENTRY OF PATIENTS AT MEDICAL RESPITE (2007–2010)
Table 1.
0.55 0.49 0.65
1.16 1.45 1.06 0.82 0.97 0.69
0.88 1.20 1.05 1.68
1.39
1.65
0.66
(0.81, 1.68) (0.85, 2.48) (0.69, 1.65) (0.51, 1.34) (0.57, 1.64) (0.34, 1.21)
(0.66, 1.18) (0.90, 1.62) (0.97, 1.14) (0.74, 3.80)
(1.04, 1.86)
(1.17, 2.34)
(0.47, 0.93)
95% CI
(0.40, .074) (0.28, .087) (0.47, 0.91) (Continued on p. 1098)
Odds Ratio
177 41 40 1 3 191 161 235 224 147
Circumstances before entry Living outside, encampment, car* Sheltered Unstably housed (living with friends) Hospital* Renting room or apartment
Resources and services at entry No primary care provider Uninsured (no med coverage) No income at entry** No ID at entry** No services connections reported
*P value .05 **P value .01 AMA 5 Against Medical Advise AWOL 5 Absent Without Leave CI 5 Confidence Interval
216 130 104 61 152
N
69 58 85 81 53
64 15 14 .4 1
78 47 38 22 55
%
Left before discharge (AMA or AWOL) (n5276)
Substance use, any** Alcohol Cocaine Opiates Substance use, no Axis I**
Table 1. (continued)
379 353 441 424 318
332 110 92 14 18
408 257 184 112 223
N
Discharged (n5584)
65 60 76 73 54
57 18 16 2 3
70 44 32 19 38
%
1.22 .92 1.86 1.63 .95
1.36 0.75 0.91 0.15 0.35
1.55 1.13 1.31 1.20 1.98
Odds Ratio
(.89, 1.65) (.79, 1.23) (1.27, .2.72) (1.14, 2.31) (.72, 1.27)
(1.00, 1.82) (0.51, 1.10) (0.61, 1.35) (0.03, 0.92) (0.10, 1.18)
(1.11, 2.17) (0.85, 1.51) (0.98, 1.77) (0.84, 1.69) (1.49, 2.65)
95% CI
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Table 2. CHARACTERISTICS ASSOCIATED WITH LEAVING BEFORE DISCHARGE (AMA/AWOL) MULTIVARIATE REGRESSION MODEL Patient characteristics Female* Under 50 years old No income at entry reported** No identification at entry Substance use without Axis I diagnosis** Living outside prior to hospitalization and Respite**
Odds Ratio
p value
1.76 1.44 2.04 1.62 1.94 1.44
0.00 0.07 0.00 0.16 0.00 0.01
*P value .05 **P value .01 AMA 5 Against Medical Advise AWOL 5 Absent Without Leave
Community based health care and housing referrals. Patients who left AMA or AWOL were significantly less likely to be connected to community based medical, mental health and substance treatment services by Respite staff than other patients (Table 3). Separate analyses (not shown) indicated that patients leaving early were no less likely to be offered service referrals than other patients when adjusting for length of stay. However, patients who left AMA or AWOL were more likely to decline service referrals than other patients (Table 3). There was a considerable disparity around uptake of medical services; among patients who entered without an established primary care provider, 29% of patients who left early declined primary care referrals compared to 5% of other patients (Table 3). Another significant disparity was in connection to supported housing: 4% of patients who left early started a supported housing application, compared with 29% of other patients. Emergency room and hospital admission within 90 days. In all, 41% of patients were admitted to the emergency room within 90 days of leave Respite and 20% were admitted to the hospital (not shown). Table 4 shows likelihood of emergency room and hospital readmission within 90 days of Respite exit among all exit dispositions compared to discharge to self (reference). Patients who left AMA were significantly more likely to be admitted to emergency room (OR 1.78) but not hospitalization, while patients who left AWOL were significantly more likely to be admitted to both emergency room (OR 2.11) or hospital (OR 2.98) compared with patients who completed medical and discharge plans before being discharged to self. Increased risk of readmission was not significant when adjusting for substance use (Table 4). Independent tests (not shown) also found that substance use and living outside before entering Respite were associated with both greater likelihood of leaving AMA/AWOL and readmission within 90 days. Using a multivariate logistical regression model that
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Table 3. SELECTED OUTCOMES FOR PATIENTS AT MEDICAL RESPITE Patients who left before discharge (n5276)
Completed medical treatment plan* Length of stay in Respite Less than 7 days** More than 30 days* Referrals by Respite staff Primary medical provider** Mental health provider* Substance abuse treatment** Supported housing (applied)** Referrals declined by patients Primary medical provider** Mental health provider** Substance abuse treatment**
Discharged patients (n5584)
N
%
N
%
Odds Ratio
95% CI
60
22
450
77
0.08
(0.06, 0.12)
112 40
41 14
48 305
8 53
7.63 0.16
(5.22, 11.15) (0.11, 0.23)
79 10 10 11
41 14 5 4
273 65 44 164
72 29 12 29
0.27 0.30 0.40 0.11
(0.19, 0.39) (0.15, 0.59) (0.19, 0.81) (0.06, 0.20)
33 21 33
29 68 77
13 34 60
5 34 58
3.08 4.00 2.42
(4.40, 17.5) (1.70, 9.48) (1.07, 5.42)
*P value .05 **P value .01 CI 5 Confidence Interval
included substance use and leaving AMA/AWOL, the likelihood of readmission among AMA/AWOL was not significantly higher than for other patients (Table 4).
Discussion Effective strategies to reduce rehospitalization include patient engagement, education and ongoing aftercare support from health care providers.18,19 Medical Respite programs employ these strategies as a bridge for high needs patients to aftercare services, and discharge planning is a critical component of this model. A study of Respite in Chicago examined hospitalization within 90 days of Respite exit found a similar proportion of patient readmission (20%) than was found here.23 As hypothesized, there were significant differences by exit disposition. Excluding patients discharged to a higher level of care, patients at highest risk of rehospitalization were those who were discharged due to rule violation, followed by those leaving AMA or AWOL. Given the high proportion of patients who leave Respite early, and differences in
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Table 4. LIKELIHOOD OF ADMISSION TO PUBLIC EMERGENCY ROOM OR INPATIENT HOSPITAL WITHIN 90 DAYS OF MEDICAL RESPITE EXIT, BY EXIT DISPOSITION Emergency room admission Patient exit disposition Discharge to self (referent) Against Medical Advice (AMA) Absent without leave (AWOL)* Discharge for rule violation** Discharge to treatment program or medical facility (excluding hospital) Discharge to hospital** AMA or AWOLa
Hospital admission
Odds Ratio
95% CI
Odds Ratio
95% CI
1.0 1.78* 2.11** 3.21** 0.98
— (1.05, 3.01) (1.47, 3.04) (1.95, 5.28) (0.45, 2.12)
1.0 1.59 2.98** 2.83** 1.97
— (0.72, 3.53) (1.78, 4.98) (1.45, 5.52) (0.63, 6.16)
3.29** 1.35
(1.91, 5.68) (0.99, 1.84)
7.63** 1.32
(4.00, 14.53) (0.87, 2.00)
*P value .05 **P value .01 a Referent group is all discharged patients, adjusted for current substance use and living on the street before Respite entry. CI 5 Confidence Interval
length of stay, connection to community based medical provider and other supports and rate of rehospitalization, AMA and AWOL patients are an important population of concern. For providers, identifying patients at risk of leaving early can be a critical first step in developing interventions to serve them better. Several associations found here indicate that early exit from Respite may be linked to differences in engagement, motivation, and trust among patients. For example, patients who had been living in a shelter were more likely to stay, while immediately history of living outside was associated with early exit. These patients may have felt constrained by Respite structure, but also may have been following a pattern of behavior that—for many reasons—resulted in discomfort or disinterest in engaging with service providers. Similarly, patients who left Respite early were also significantly more likely to decline other services when offered: these included primary care, case management, supportive housing, and even income benefits. Women in this study were significantly more likely to leave Respite before discharge completion than male patients. Given the prevalence of victimization among homeless women and the association of trauma to fear and social withdrawal27–28 re-traumatization from lack of privacy, sense of scrutiny, or power dynamics may all contribute to earlier exit among female patients. Experience with other facility based treatment indicates
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that gender specific treatment models or women-only spaces may enhance retention outcomes. Research on treatment models for homeless substance users, suggests that distrust is a stronger barrier to engagement among women: drug treatment programs that are successful are those that address women’s victimization and create safe space.29,30 Research also consistently finds higher retention among programs that are women-only, rather than mixed gendered.29 Although male and female patients are housed in different parts of the Respite facility, real or perceived risk of victimization may impact female patients’ early departure. Additional research should explore how trauma impacts female patients’ experience at Respite. Substance use was the strongest risk factor for early Respite exit. Although patients can leave the facility, SFDPH Medical Respite requires that patients abstain from using substances in the facility. While factors that range from feelings of constraint to distrust may impact early departure, these patients may also leave early due to desire to use.29 Notably, in this study, dually diagnosed individuals were more likely to finish treatment than patients without a mental health diagnosis. The reasons that dually diagnosed Respite patients were more likely to stay are unclear. It is possible that these patients perceived a greater need for ongoing care; it is also possible that medication management provided at Respite enhances compliance which may positively affect retention. The link between substance use and frequent hospital use is well documented in other literature.31 In this analysis, substance using individuals were significantly more likely to be rehospitalized than other patients, even when adjusting for discharge disposition. This further indicates that completing treatment may not have the same benefit for substance using patients than other patients. Moreover, it should be noted that even patients who completed Respite often declined referrals for substance abuse treatment. While outcomes are not uniform across all Respite patients, this study also showed the important role that Medical Respite can fill in linking patients to ongoing community based care and housing programs. Over half of all patients reported no community based service connections at intake and many left with critical linkages in place. Respite provided opportunities for engagement with many patients: over half were connected to ongoing primary care and supportive housing processes were started for over one fifth of all patients. Further research should examine models and methods to enhance retention for Respite patients, given the benefits of completing care. Limitations. There were several limitations to this study. This was a retrospective study relying on medical and program records. Rates of psychiatric comorbidities and substance use may have been underestimated, leading to incorrect assumptions about completion of treatment. Additionally, this study was conducted in one model of Respite care with a limited, though relatively large, patient population. Though there are limited data to characterize different homeless populations, some published data suggest that San Francisco’s homeless population has a particularly high prevalence of intravenous drug use.32 Rates of IVDU were not captured for this study and thus could not be analyzed. It is possible that other Respite programs might encounter different outcomes. Looking specifically at patients who choose to leave compared with all other patients, there may be differences within the comparison population that affected outcomes.
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Patients discharged due to rule incidents may have been less likely to engage and may have left before treatment completion if they had been allowed to stay. Patients discharged to a higher level of care may have been less likely to receive services than patients who were discharged to self-care. No qualitative data was collected about patients’ decisions to leave early (e.g., through exit interviews). Although data included a variety of factors previously associated with leaving AMA, a number of other factors may influence AMA in ways we could not determine. For example, perceiving oneself as healed, having obligations outside of the facility, distrust, or—as has been discussed—desire for more control or simply feeling constrained may all contribute to early departure. These more subtle motivations cannot be determined by our analysis. Additional qualitative research or exit interviews may be helpful in providing a more complex and complete picture of individuals’ motivations. Using SFDPH records to measure readmission only includes patients who were admitted to SFGH emergency room or inpatient ward post-Respite discharge. San Francisco General Hospital is the city’s only public hospital and serves a large proportion of the homeless, and 78% of patients entering Respite were referred from SFGH. However, there are other community-based hospitals where patients may have been treated post-Respite: patients picked up by an ambulance may be taken to the closest community hospital, rather than SFGH. While it should be noted that SFGH is often the first place homeless or indigent patients are taken for emergency room care, inability to track admission to other hospitals is a limitation here. Conclusion. This is the first study to examine patients who choose to leave Medical Respite AMA or AWOL. Between 2007–2010, 31% of Respite encounters ended when patients left AMA or AWOL, while 45% were discharged to self after completing medical and discharge plans. Female patients, patients who had been living on the street (rather than shelter) and patients without public benefits were all significantly more likely to leave before discharge. In addition, patients who were substance abusers without an Axis 1 diagnosis were significantly more likely to leave AMA or AWOL, while patients with dual diagnosis (substance abuse and Axis 1) were more likely to finish treatment. Patients who left AMA and AWOL stayed significantly fewer days in Respite and were significantly less likely to complete treatment plans than other patients. Further, while Respite helped establish ongoing medical support and housing for many patients, AMA and AWOL patients were significantly less likely to have these services in place at exit. While rate of readmission overall was similar to previous research on the impact of Respite, leaving early was associated with increased risk of rehospitalization—though not significant when adjusting for substance use. Given the high rate of patients leaving before treatment completion and differences in key outcomes by exit disposition, further research should continue to examine how to better identify, retain and serve patients at high risk of leaving Medical Respite early.
Acknowledgments The authors wish to acknowledge Maria X. Martinez at the San Francisco Department of Public Health and Carol Chapman for their work on the CCMS database.
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