Nowhere else to turn

When asked about the most serious health care issues facing the nation, Americans consistently name cost and access as the two most pressing problems. This has been the case since at least 2001, when the pollsters at Gallup began posing the question each November. Last year, 42 percent chose one of the two as the biggest challenges to living healthy.

It’s likely most Gallup respondents have some combination of a job, a home and a health care plan, which prompts a question: How can members of the homeless population, who often lack the most basic resources, get the health care they need to survive?

In her role as case management supervisor at Enloe Medical Center, Amanda Wilkinson comes face-to-face with impoverished people attempting to access health care on a daily basis. Wilkinson and Oroville Hospital CEO Robert Wentz were invited to speak at last month’s Homeless Symposium, a gathering of stakeholders organized by the Butte Countywide Homeless Continuum of Care, to discuss the impact of homelessness on local hospitals (see “All hands on deck,” Newslines, April 21). Wilkinson offered more information during a recent follow-up interview.

“The homeless population has so many barriers already that I sometimes wonder how they can find the motivation to navigate something that can seem so insurmountable,” Wilkinson said of the health care system. “You have people who are saying, ‘I’m worried about where I’m going to sleep tonight,’ not ‘I’m worried about how my diabetes will be in a month.’ They walk out of the emergency department or after being admitted to the hospital for a few days feeling better, with their symptoms under control, but end up having to revisist for the same condition.”

Some of the access issues homeless individuals experience are not having a phone number or address for staff to contact them regarding follow-up care, a lack of transportation and finding skilled nursing facilities that will accept them as patients despite lack of insurance or funds. A broader issue is the general scarcity of primary care physicians. The lack of access to follow-up or preventative care leads to heavy impacts on emergency departments and prompt-care facilities, Wilkinson explained.

“One of the highest concerns we face are the high-frequency [patients] that we see. In some of the most extreme cases, we’re seeing them on a daily or every-other-day basis,” she said.

At the symposium, Wilkinson offered some quantitative information about the direct impacts of the local homeless population on Enloe, with the caveat that such data is incomplete and hard to obtain because hospitals don’t specifically ask patients whether they are homeless.

“Everyone gets treated, no matter what,” she emphasized.

To gather the data, hospital staff pulled information from patients who listed local shelters, such as the Torres Community Shelter, or wrote “homeless” on their intake papers.

Based on that limited data, 2,835 homeless individuals checked into Enloe from July 1, 2012, to June 30, 2013, not accounting for multiple visits by the same patient. The total charges incurred by the hospital after receiving Medi-Cal or other payments was $10.2 million. Between those same dates in 2014-15, the hospital saw 3,810 homeless patients, with $14.2 million in unpaid charges.

Wilkinson said the number of patients who visit Enloe, homeless or otherwise, is on the rise. The hospital is licensed to fill 228 beds, and a few years ago averaged about 160 patients daily. The average today is closer to 200, and the hospital recorded its highest monthly census numbers ever in February, with an average of 206 patients.

“We’re bursting at the seams,” she said.

Wentz also spoke at the symposium and reported similar issues.

“When people talk about getting homeless people off the streets, a lot of times they mean getting them into the hospital,” he said. “A lot them end up being admitted because of their living situation, and a great deal of them don’t have medical situations other than their psychiatric condition.

“It costs the hospital about $1,500 to $2,000 for every patient that comes in, and that’s a conservative estimate,” he said. “That’s a couple million dollars spent on homelessness right there.”

The 12 most common reasons for homeless individuals to visit Enloe’s emergency department were diabetes; alcohol-related issues; mental health/suicidal ideation; drug abuse; respiratory issues; mouth and teeth pain; back pain; general symptioms; chest pain; injury; and prescription refills.

Wilkinson said the list isn’t much different from what causes housed individuals to seek medical attention, but that all of the conditions can be exacerbated by living on the streets. A patient’s homeless status also can lead to longer hospital stays.

“We’re obligated to provide a safe discharge plan, which looks a lot different for [a housed person] than someone who is homeless,” she said. “We’re not going to send someone into the streets when it’s not safe for their health. We take the time to figure out the best solution.”

To that end, Wilkinson said Enloe partners with Behavioral Health, as well as local service organizations and shelters, to better serve the homeless population. The hospital has case management and social workers assigned to every unit, and more on duty in the emergency department from 7:30 to 1 a.m., to help homeless patients connect with various social services. She said Enloe provides basic assistance to homeless patients, like bus fare, some medicines and medical supplies.

“Our philosophy is really to build bridges and partnerships to strengthen the safety net we’re trying to provide,” she said, adding that the symposium was a good start to cooperation between agencies and looking at homelessness from all vantage points. She would ideally like to see a local coalition dedicated to addressing the health care needs of the homeless population formed in the near future.

“I feel like there is some movement, that there is actual connection and collaboration happening.”