Editor’s note: This story was produced in conjunction with Curbside Chronicle.
Howard Holten slept in the Integris Southwest Medical Center emergency department the night he left an Oklahoma City rehabilitation hospital frustrated with his discharge plan.
In July, Holten was riding his bike when a car struck him from behind in a hit-and-run accident, fracturing his left hip. Scratches from the accident still dotted his arms weeks later. Holten, 56, has spent much of his life in and out of homelessness. He spent an anxious two weeks at Jim Thorpe Rehabilitation Center, part of the Integris Health system, recovering from major hip surgery and trying to figure out where he’d go after he left the hospital.
“It was so painful,” Holten said. “I had to have someone help me even to stand up.”
The Integris social worker involved in Holten’s case called five shelters, but they were all full or didn’t call back. Plans to stay with a friend fell through. On his scheduled discharge day, Integris sent Holten to a shelter that immediately sent him back to the hospital because he was too unsteady on his feet for the shelter to safely care for him, according to Holten’s medical records.
Oklahoma City has limited resources for people experiencing homelessness after they’ve been medically cleared for discharge from a hospital. Hospital social workers often have few options but to discharge people to the street, typically armed with a bus pass, or to send them to local shelters. Oklahoma City’s four largest hospital systems told The Frontier that they do not have specific procedures for how to discharge homeless patients, apart from general discharge policies that apply to all patients, which are modeled after federal guidelines.
Multiple hospitals said that they consider shelters a safe discharge option, though homeless advocates say shelters are not the right place for those recovering from medical issues and that the lack of quality communication and planning between shelters and hospitals jeopardizes the health and safety of vulnerable people without housing.
Between 2016 and 2020, Oklahoma health care providers made nearly 2,500 discharges to homelessness from inpatient and outpatient facilities, according to data from the Oklahoma State Department of Health. In addition, there were more than 2,700 discharges to homelessness or shelters from emergency departments in the state in 2020 alone. Over half of people experiencing homelessness who received outpatient or emergency room services since 2016 didn’t have health insurance, according to state data. The most common diagnoses for people discharged from a hospital to a shelter or the street were mental disorders or diseases, followed by infections, respiratory issues and musculoskeletal problems.
Holten frequently experienced anxiety about the accident during his recovery. He had nightmares and cried when he heard racing cars. His frustration grew as he and hospital workers struggled to find him somewhere to go.
The hospital social worker called five more service providers. With Holten’s health issues and no valid personal identification or active substance abuse problem, it was difficult to find a shelter Holten was qualified to stay at that wasn’t full. Holten was told he could try to find a bed at City Rescue Mission, a religious, program-based shelter in Oklahoma City, but he said he didn’t feel safe going there. Holten left the hospital six days after his original discharge date, upset and against medical advice.
Hospital security found Holten a few hours later and took him to the emergency room for a check up. Holten said staff told him he couldn’t be readmitted to the hospital. With nowhere else to go, he slept in the emergency department.
Holten still relied on his walker, and one progress note said he needed special bed equipment, bathroom assistance and oxygen. He had prescriptions to control his pain, and his risk of falling was high, according to medical records.
Between 2016 and 2020, Oklahoma health care providers made nearly 2,500 discharges to homelessness from inpatient and outpatient facilities.
via Oklahoma State Department of Health
The next evening, hospital case management staff paid $12.75 for a yellow taxi cab to drop Holten off outside of the City Care Night Shelter. A day later, he climbed onto a city bus toward the Homeless Alliance, a day shelter.
Homeless Alliance staff were able to get Holten into Oklahoma City’s only respite center, which has five beds. The respite center only accepts unhoused people who can handle most daily living activities on their own but need a safe place to recover from medical issues. Oklahoma County funds the respite center, which is staffed by Catholic Charities and Cardinal Community House. The facility has been full since it opened in March 2021.
Holten still struggles with flashbacks from the accident, anger at the person who hit him and confusion about his future. His time in the hospital caused him to lose the garage he was renting for $45 a month, along with his few possessions. He still required follow-up medical care for his hip in the months after the accident and needs another surgery on his neck.
Holten doesn’t know exactly what will happen when he eventually has to give up his bed at the respite shelter.
“Although they tell me that later, it gets better and better, I don’t know for sure that is true,” Holten said through tears a few weeks after his knee surgery. “What’s going to happen now?”
Shelters aren’t equipped to provide health care, and hospitals mostly provide acute care, which the federal government defines as inpatient medical care for surgeries, acute medical conditions and short-term illnesses or injuries.
If a patient is medically stable — typically meaning no fever in 24 hours, not on any intravenous medications and neurologically stable — hospitals will work to discharge them, said LaWanna Halstead, vice president of quality and clinical initiatives for the Oklahoma Hospital Association.
“I know it sounds kind of difficult to say, ‘Well, a patient would be sent from a hospital to a homeless shelter.’ But if they no longer require medical treatment, ongoing medications, things like that, they don’t have a need to stay in the hospital,” Halstead said.
Before Oklahoma expanded Medicaid in 2021, many homeless individuals did not historically qualify for state-funded insurance, and without a payment source, couldn’t get admitted to most long-term or short-term care facilities.
Instead, hospitals employ staff social workers to find people without homes somewhere else safe to go before discharge. Because there are often no other options, hospitals frequently discharge homeless patients back to the street or make transportation arrangements for drop offs to a local shelter.
Oklahoma City homeless service providers say that for years, hospitals have used police or taxi services like Medride or Uber to drop people off outside of shelters without adequately warning staffers that a person with a health issue was coming. In some cases, providers said, people without housing were discharged to the street and walked to a shelter by themselves, some still wearing a hospital gown or bracelet.
People experiencing homelessness often have chronic physical or mental health issues, and they also often put off seeking medical care until an emergency, said Meghan Mueller, a social worker and associate director of the Homeless Alliance. After a visit to an emergency room, the unhoused can get shuffled between shelters and hospitals as case managers try to find a permanent placement.
Hospital administrators from Oklahoma City’s four largest medical systems told The Frontier that they only discharge patients once they’re medically stable, but the hospitals don’t have the resources to keep people experiencing homelessness until their health issues are completely resolved or they find housing.
But hospital standards on who needs care often run counter to who can function successfully at a homeless shelter, said Shelly Sheaffer, former director of programs and quality assurance for City Rescue Mission.
“Hospitals may discharge somebody who’s not medically needy. But we’re looking at a situation, are they able to get their own meds? Are they able to get to a doctor if they regress?” Sheaffer said. Even though hospital staff know these gaps exist, she said, the solution isn’t necessarily that hospitals keep homeless individuals until they find housing.
Better communication between hospital social workers and shelters would help, Mueller said, but a lack of resources is the real issue.
“I totally understand that hospitals are saying, ‘This person is not acute-care appropriate. They don’t need a hospital,’” Mueller said. “On the other hand, discharging to homelessness is not OK. But I think, a lot of times, that the place for someone to be discharged doesn’t exist.”
DROP EVERYTHING
The line at the City Care Night Shelter still snaked out the door over an hour into the check-in process one night last September. Roughly 150 people filed into the dorms for the night, putting the shelter over its 140-bed capacity. Several people had wheelchairs or crutches. Some relied on staff at the front desk to administer prescription medication.
The shelter only had three staff members on duty for most of the night. One employee described the nights as a “whirlwind,” with staff running check-in, security and storage. City Care runs Oklahoma City’s only low-barrier shelter providing overnight beds. It’s open to anyone without requiring sobriety, enrollment in a work program, or attendance at religious services. The facility opened in April.
Assistant shelter director Nic Hackler called an ambulance to transport a woman with a broken foot and heat exhaustion to a hospital. One man who goes by the name “Reaper” checked into the shelter and walked to the nearest wall for support before collapsing to the floor in pain.
Reaper agreed to speak with The Frontier, but he didn’t want his full name published because of safety concerns.
Reaper, 65, has alcoholic liver cirrhosis and said he was recently told he’s terminal with only four to six months to live. He’s been homeless throughout his life. A week before, Reaper had been taken from the night shelter to be treated at SSM Health St. Anthony Hospital for severe abdominal pain and a fainting episode.
He was discharged around 3 a.m. with instructions for what to do if he fainted again and a directive to follow up with Healing Hands, a clinic in Oklahoma City for people experiencing homelessness. Then, Reaper said, he walked the two miles to the night shelter to stay with his wife of 28 years.
“If you’re homeless with no insurance, they don’t care. When they find out you’re homeless without insurance, they do the least they can do for you,” Reaper said. “It really hurts.”
Reaper’s wife, Jean Duggan-Childers, said the hospital told her to find hospice care for her husband. “Where am I going to get hospice to come for him? Here?” she said.
City Care staff said they were aware of Reaper’s health issues and that he frequently bounces between the shelter and hospital stays. Reaper said in October he had finally been approved for health insurance coverage under SoonerCare, Oklahoma’s Medicaid program.
Many people who find their way to the night shelter have some sort of existing chronic, mental or physical health challenge, Hackler said.
In recent months, night shelter staff have had to call an ambulance for a handful of people with wounds on their hands or feet who later came back to the shelter with fresh amputations, Hackler said. Other times, people with recent amputations arrive in the check-in line on their own.
When someone is dropped off from a hospital or shows up with a serious health issue, it forces shelters that are understaffed and over capacity to drop everything else. An individual with a fresh or open wound at the night shelter “poses a huge health and safety risk to everyone in our building,” Hackler said, because it can leave the amputee vulnerable to infection and also expose other medically compromised people to unsanitary conditions.
“For someone who isn’t trained or skilled in this profession, it would be extremely difficult to see another human being in that state,” Hackler said. “Why isn’t this person receiving care? Why is no one taking care of them? Where’s their family? … Questions that come to mind are why would no one else help them? How am I the first person seeing this and trying to do something about it?”
About 50 percent of homeless service providers in the state said health care providers were doing a poor job of planning to discharge people to permanent housing rather than shelters, according to a survey the Governor’s Interagency Council on Homelessness conducted in late 2018.
The Homeless Alliance shelter just west of downtown Oklahoma City is usually only open during the day, but transitioned to provide emergency beds for people overnight during an ice storm in October 2020. Late one evening after the power and phone lines went out and rain and ice were pouring down outside, a ride-share driver rolled a man in a wheelchair wearing a hospital gown and a catheter bag into the shelter, according to Homeless Alliance director Dan Straughan.
“It was absolutely clear that he had no business being in an emergency homeless shelter with no lights and no heat,” Straughan said. “So I questioned his escort. And the escort said, ‘Well, the hospital told me they called and you OK’d it.’ And I lost my temper and said ‘That’s a damn lie. We don’t even have phones.’”
The driver eventually took the man back to the hospital. Even if the man didn’t need hospital-level care, Straughan said, a temporary shelter without electricity and floor mats for beds was not the right place for him.
Homeless shelters can sometimes pay for short-term hotel stays for people discharged from hospitals without a place to stay, but it depends on how much money is available at the time and what condition the person is in, Straughan said.
Mueller fields several calls or emails a week from hospital social workers asking if she has any recommendations on where to send a person without housing after discharge. She estimated hospitals facilitate the drop off of one person every week at the day shelter who is confused about where they are and holding a sheet of paper saying they’ve just been discharged.
Straughan and other service providers said Oklahoma City shelters have started sending people back to the hospital if their ongoing medical needs can’t be met in a shelter. The federal government can lower reimbursement rates temporarily for hospitals that are found to have excessive readmission rates for Medicare patients with certain health issues.
Shelter workers said it’s one of the few ways to put pressure on hospitals to make better discharge plans for homeless patients.
But the practice can cause patients to bounce back and forth between hospitals and shelters.
“It’s not good for anybody, but mostly it’s not good for the person,” Sheaffer said. “They’re unsettled. They can’t rest. It’s not very dignified to play ping pong with the person.”
Hospitals need to do more to communicate with shelters on where a homeless individual is in the process of enrolling in Medicaid and other forms of public assistance before discharge, Mueller said. Enrolling in those programs can take time, but the quicker a person is accepted for benefits, the more likely they will be able to find housing and address health problems.
“By the time the person is actually in our lobby, we don’t know where they’re at in those processes. We might as well be starting from scratch,” Mueller said.
SWIMMING UPSTREAM
Cindy Maggart settles into her office at Mercy Hospital in Oklahoma City around 7 a.m. on most mornings.
By 8 a.m., Maggart, the hospital’s director of post-acute care services, is in a discharge planning meeting to go over the roughly 60 patient discharges that happen each day. Then she meets with the more than 30 social workers and case managers who make plans for hard-to-discharge patients, including people experiencing homelessness.
Hospital staff ask patients about where they live and what kind of support systems they have. If a patient previously stayed at a homeless shelter, it’s the social worker’s job to call the shelter and ask if they can keep up with the person’s medical needs.
“When patients are homeless, and they have medical needs, we don’t discharge them back into the community without that safe discharge plan,” she said. “That’s just not something that we do. We have to be able to provide and show that we’ve arranged for things that they’re going to need.”
If a patient experiencing homelessness has medical needs that are less extreme, like dehydration or being off of long-term medications, the hospital will work with them until they are medically cleared and then offer them transportation back to where they had been staying, Maggart said.
“It’s actually really hard,” Maggart said about knowing someone may go back to a shelter. “It’s heavy on us here. It really pulls at our heartstrings for our patients when they come in and we know that they are homeless.”
Oklahoma City’s four largest hospital systems — Integris, SSM Health, Mercy and OU Health — all have care management teams, which coordinate discharge efforts for patients.
The discharge process is fairly standard across the hospitals, said Darin Smith, vice president of operations at SSM Health St. Anthony Hospital. Doctors evaluate the type of acute care a patient physically needs, and a hospital typically discharges that person after providers treat those needs, Smith said. Along the way, care management teams work with the patient to determine whether they have housing, food or clothing, and if they can pay for medications and get to follow-up appointments. If not, the hospitals will try to provide those items.
“Usually there’s a flurry of activity up to discharge with that individual to try to make sure we’re ready to meet those needs as quickly as we can once the physician deems them ready for discharge,” Smith said.
The hospital systems said they don’t have specific policies for discharging patients experiencing homelessness because each patient has unique needs, but hospital administrators said they were aware of the problems facing homeless patients, shelters and health care providers upon discharge.
The hospitals may try to connect homeless patients with the Homeless Alliance or Variety Care, a non-profit community health organization, for further resources. Some hospitals said they offered food, clothes and toiletries along with transportation options when they discharge homeless patients.
“I really do feel like people want to do the right thing. It is just a challenging situation,” Smith said. “And sometimes it’s on the system, sometimes it’s on the individual.”
People spent an average of seven days at inpatient facilities before being discharged to homelessness or a shelter, according to the state health department.
In an interview with The Frontier in August, Halley Reeves, who was then vice president of community and rural health impact for OU Health, said there is a financial incentive for hospitals to discharge patients as quickly as possible. It’s expensive to keep a patient in a hospital room when they no longer need acute care, and hospitals will also sometimes pay for hotels or other short-term accomodations to make room for new patients.
“What’s so challenging with this is there’s a bed that’s taken up. And that person, if they had a place to go, could go somewhere and actually have the opportunity to get healthier,” Reeves said. “We need as much opportunity for our staff to provide services to as many people as possible. And so if there’s people that we cannot discharge because they don’t have a place to go or for whatever reason, it often creates a problem.”
Reeves has since left OU Health. The hospital said in a statement in December that it does not discharge patients to the street or pay for transportation to homeless shelters. The statement also said that OU Health follows all federal guidelines for discharging patients. A representative for the hospital said it considers shelters a safe discharge option.
Hospitals said their care management teams are doing their best with limited resources, but getting individuals into shelter programs, skilled nursing facilities or long-term care facilities is difficult. Space can be limited, application processes take time, and individuals have to medically qualify, agree to stay in one of the facilities and have a way to pay.
Hospital social workers can start the process of applying for Medicaid or other welfare programs, as well as helping patients get new photo IDs or other documents. But those applications can take months or years.
Communication can easily break down between homeless shelters and hospitals because of a lack of relationships and staff turnover, Maggart said. Hospital staff try to contact shelter workers before sending a newly released patient, but shelters aren’t always staffed 24 hours a day, seven days a week, like hospitals. Sometimes people experiencing homelessness also disagree with the hospital’s discharge plans and decline to go to a facility or shelter.
“It is like swimming upstream,” Reeves said.
FINDING HIS FOOTING
Holten began to feel hopeful after he moved into the Oklahoma County respite center in early August. The staff there seemed to care about his recovery, he said.
At the respite center, Holten said he is receiving case management for the first time, which can include help signing up for federal and state welfare programs, getting into mental health treatment, navigating the court system and finding housing.
A couple of weeks after moving into the respite center, Holten still gripped his walker tightly and shuffled his feet along as he navigated the shelter’s doorways and sidewalks. Shelter workers had to call for an ambulance twice for Holten over the last few months when his pain became too much.
The respite center can’t provide medical care or accept people who need help showering or using the bathroom. People with chronic illnesses are frequently denied, said Christi Marshall, director of social services for Oklahoma County.
“The need is so much broader than what our program is able to do,” Marshall said. “But it’s nice to be able to step in on one piece of it. And our hope is that other pieces will develop with other entities and somebody will pick up a more medical-type respite.”
Catholic Charities of the Archdiocese of Oklahoma City, which currently provides case management at the respite center, hopes to eventually set up a larger respite center staffed with nurses and case managers to assist people with higher-level medical needs.
All four of Oklahoma City’s largest hospital systems have been included in conversations about the medical respite centers, but plans have been slowed by the ongoing coronavirus pandemic, said Patrick Raglow, director of Catholic Charities.
“It’s so much cheaper than what the hospitals have to do now,” Raglow said. “It won’t answer all of the hospital systems’ needs, but it will answer a need and that allows them to focus their attention on other unmet needs in the community.”
Social workers, shelter staff and hospital administrators said a larger respite facility would be helpful. But a medical respite center would only be part of the answer.
Oklahoma has high rates of poverty, evictions, mental illness, incarceration and substance use disorders. As homelessness and housing costs continue to increase in Oklahoma City, connecting people to preventative health care and permanent housing will be what addresses the underlying issues.
By late October, Holten’s cheeks had filled out, and his steps came more quickly and confidently.
He’s collected a new copy of his birth certificate, which he keeps filed in a black zip-up briefcase. His case manager helped him get approved for a housing voucher, and he is working with lawyers on his hit-and-run case.
Staying in the respite center after his surgery didn’t solve all his problems, Holten said, but it did give him the space to safely recover while he figures out his next steps.
“Even though it might be difficult,” Holten said, “I still have to try.”
