A hospital discharges a man after surgery with instructions to change his wound dressing three times a day and refrigerate his medication. But he’s homeless, living in a tent, with no transportation, limited access to running water, no money to buy supplies and a refrigerator nowhere in sight. Chances are his recovery is not going to go well, with re-hospitalization likely and severe infection or even death a real possibility. But it doesn’t have to be.

Covering the gap between discharge and full recovery is where Donna Biederman, DrPH, MN, RN, assistant professor for Duke University School of Nursing (DUSON), and her colleagues have set their sights. Supported by a $600,000 Hillman Innovations in Care Program grant, the Durham Homeless Care Transitions (DHCT) project aims to stop the cycle of preventable health crises and get the homeless connected long term to existing services.

“We’re a facilitation service. DHCT provides navigational services to those who either cannot navigate or have difficulty navigating the health care system themselves,” said Biederman, who helped advance the program with Julia Gamble, MPH, nurse practitioner for the Duke Outpatient Clinic, and Sally Wilson, executive director of Project Access of Durham County (PADC). Both Gamble and Wilson have been working on developing such a model for years. “Durham is full of a lot of great agencies. It’s just getting people to those agencies that’s the problem,” Biederman said.

The Durham effort is one of a growing movement of medical respite services. As of 2016, there were 78 programs registered with the National Health Care for the Homeless Council. Biederman serves on the council’s Respite Care Providers Network Steering Committee.

Getting Connected

Homeless patients who are discharged from a hospital following emergent care or post-surgery can have difficulty adhering to their recovery protocol for a number of reasons: no safe or clean place to recover, no transportation available for check-ups, no financial resources for prescriptions. Some patients may have literacy or cognitive or mental health issues that prevent them from following instructions correctly. More than just providing respite care for patients as they leave the hospital — securing temporary housing for recovery — DHCT also seeks to connect patients to existing agencies that can help them not just with their health care but with all aspects of their lives. “Sometimes people come out of the hospital, and they don’t really need the full service of medical respite,” Biederman said, “but they do need to get connected to community resources and support.”

Staffed by two community health workers and a nurse care manager, the program’s first goal is identifying and working with the homeless at one of their most vulnerable moments and guiding them not just to the medical support they need but toward overall healthier living. Long term, Biederman said she wants to see medical facilities, which referred the majority of patients during the program’s pilot phase, incorporate transitional care into its model of overall patient care for the homeless, something that has been done in scores of cities and towns across the country.

Referrals to the program come through local clinics that have access to a computer link that connects directly to PADC Executive Director and Hillman Grant Administrator Wilson. She determines whether the patient has appropriate need, and if so, then the nurse or one of the two community health workers connects in person with the patient, ideally before they leave the hospital. This face-to-face meeting is critical to establishing trust.

Emily Lybrand, a community health worker on the project, said part of building that rapport is understanding the homeless patient’s circumstances. “These people are survivors,” Lybrand said. “They know what they need to do to survive, but it doesn’t necessarily translate into getting them disability or medical care assistance.” So meeting them where they are and trying to show them that instead of making $20 today, making a follow-up appointment and keeping it is going to really benefit them in the long run.

Whether their patients are in respite care or back out on the “streets,” a community health worker will accompany them to follow-up exams, primary care appointments and visits to specialists and counselors. “A lot of our people don’t understand what their doctor is saying, but they don’t want to admit it,” Lybrand said. The community health workers help the patient stay on course and keep the nurse care manager in the loop to make sure the patient is safely following medical protocols.

Gamble, a nurse practitioner who has worked with the homeless population for decades, said care management is critical because it connects the patient from the hospital and emergency department (ED) setting back to the community. “Lots of research shows that’s where mistakes happen,” she said, referring to the time immediately following discharge. For example, a patient could have visited three different medical facilities in the Durham area for the same problem. The patient could have been given a prescription at each of these facilities that turns out to be the same medication but with a different name. A homeless person with no follow-up care in a primary care setting could get into real health trouble. “We’re bridging the population from the hospital ED back out into the world. We want to make sure that work that was started in the hospital, that work that was done for thousands and thousands of dollars, can actually continue in the real world. This is where a nurse comes in.”

The nurse care manager is the person responsible for looking at the big picture. “It’s less about putting a stethoscope on a body,” Gamble said, “than a nurse using their nursing brain to say, ‘What is happening here? Let me assess the situation and triage.’”

The Obstacles

According to the National Health Care for the Homeless Council, poor health (illness, injury and/or disability) can cause homelessness when people have insufficient income to afford housing. This may be the result of being unable to work or being bankrupted by medical bills.

Living on the street or in homeless shelters exacerbates existing health problems and causes new ones. Chronic diseases such as hypertension, asthma, diabetes, mental health problems and other ongoing conditions are difficult to manage under stressful circumstances and may worsen. Acute problems such as infections, injuries and pneumonia are difficult to recover from when there is no place to rest and recuperate.

Gamble said a common misperception about homeless people is that they don’t want primary care. In fact, many don’t have health insurance, and in North Carolina, Medicaid criteria are so strict that unless they can prove a disability, they likely do not qualify.

Connecting the homeless to primary care means better health in general and better continuity of care, which reduces the need for emergent care. But if no one asks the right questions, there’s a chance a health care provider might never know their patient is homeless.

“It’s imperative to be able to identify homeless people in the medical care system, and right now we don’t have that capacity,” Biederman said. “If I don’t ask, ‘Where are you going to go home to?’ and someone doesn’t write in a medical record, ‘Patient is homeless; patient has no place to go; patient is sleeping in car’ — if no one ever says that, then we don’t know.”

There is a diagnosis code — Z59 — that indicates a patient is homeless, but it’s not being used systemically, Gamble said. “I would really like our hospitals and ER systems to identify homelessness on intake,” she said. “I’d like to have homelessness recognized as a health care problem and our emergency and hospital systems to respond to that by working across the community to help address the problems.” Patients might be embarrassed to talk about their homelessness, so the need to educate nurses in all settings to look for signs or ask the right questions is imperative.

That’s why it’s so important to continue this program beyond the three-year grant, Biederman said. The program originated through community agencies working together through a multidisciplinary group approach. Members of faith-based organization Lincoln Community Health Center’s Healthcare for the Homeless Clinic, PADC, public relations staff from Duke and a Duke care manager and complex care coordinator were all part of the initial brainstorming team that set the idea into motion.

In addition to staffing, the Hillman grant will fund educational opportunities, including sending staff to conferences and creating a presentation to share information with physicians and other health care providers about how homelessness affects health care, something Biederman already talks about in her community health classes at DUSON.

Missed appointments or failure to follow protocol are some of the obstacles to care delivery, but providers need to understand that it is often involuntary. The homeless are navigating a very different and complex context of daily life that sometimes makes compliance impossible, Biederman said. Many are cognitively impaired because of head injury, substance abuse, trauma or childhood learning issues.

The stresses of being without a home also exacerbate illness and take an overall toll on the homeless who often live in a state of fear, especially when they are physically compromised. “If you are on crutches, for instance, and you’re homeless, you can easily become a target,” Biederman said. “If you have fresh post-op wounds and you’re in the shower at the homeless shelter with a bunch of other guys, they see your wounds and probably assume you have pain medications. You become very vulnerable when you’re ill or injured in a homeless situation.”

DUSON’s philosophy of respecting and nurturing all human beings means being on alert for those who often fall through the cracks and making sure care extends past the emergency room exit. “We’re hoping to demonstrate the value of this program to the health care community,” Biederman said. “And we’re hoping that at the end of the three-year grant, we’ve shown it to be a very necessary component of primary care.”