California Law Sparks Renewed Look at Post-Acute Care Challenges for the Homeless

by Mary Kay Thalken, RN, MBA on Feb 18, 2019

woman sitting on ground with hands over her headThe majority of patients take for granted that they’ll be discharged either back home or to a post-acute facility capable of meeting their needs.

But perhaps no patients prove as great of a challenge as homeless patients who don’t have anywhere to go after their hospitalization or care episode ends. With this patient population, the bedrock of a person’s life that is used as a guidepost for appropriate discharge and care coordination isn’t available, which means adjustments must be made in the approach to meet specific needs.

Discharging a patient home isn’t an option because the person does not have a home. A lack of access to key resources (transportation, familial support, nutritious food, and other social determinants of health) jeopardizes their ability to maintain a healthy lifestyle. And homeless shelters in the area may be full or lack the resources necessary to properly care for the individual.

All these facets of the homeless experience in America make this demographic one of the most difficult to match with adequate post-acute placement. With little recourse, some facilities may opt to discharge to wherever they can find a space, even if the notation marked down in the patient’s chart is as simple as “Park Bench.”

That’s obviously not the best-case scenario for anyone, and healthcare leaders have struggled to strike a balance between freeing up beds and connecting their homeless patients with the resources and care they need to lead healthy lives.

Despite all this, progress is being made, and it’s been spurred on in part by a recent state law that’s causing hospitals to completely rethink how they approach discharge for homeless patients. Tough conversations are finally being had about how to create processes that provide optimum care for those who have historically been alienated from the mechanisms of healthcare.


The Law


The regulation in question (SB-1152) comes from California, and it has already sent ripples throughout the healthcare industry since it became active in that state on January 1, 2019.

We’ve been keeping careful track of this law, talking with industry experts and members of our Advisory Council about its potential effects and helping our clients and post-acute providers understand what they need to do to comply.

The law, at its most basic, provides protection to homeless patients with the goal of helping them receive proper care following discharge. Becker’s Healthcare breaks the law down in some detail. The big things of note for discharge planners are as follows:

  1. Hospitals need policies in place for successfully discharging homeless patients
  2. Records must be kept in regard to that discharge
  3. Food, clothing, medication and transportation must be offered to the patient
  4. Locations not reasonably considered to be care facilities (i.e. park benches, bus stops, intersections, etc.) are not admissible as discharge locations, nor are homeless shelters and other facilities that are limited in beds or otherwise lack the resources to take the individual in.

Added together, the new regulations seek to ensure a compassionate patient handoff that offers a much-improved outlook.

The Challenge


Unsurprisingly, hospitals and health systems have already run into their fair share of challenges trying to develop policies that meets the law’s stringent requirements.

I’ve spoken with colleagues who have expressed frustration that they’re basically being tasked with fixing problems that they themselves had no hand in creating. It’s not that healthcare professionals want to discharge a patient to an intersection; they simply felt like they didn’t have choice.

The problem lies in the lack of resources currently available to address the issue. California, as in many other states, has a homeless problem brought about by housing inequality, and inordinately high cost of living and myriad policy decisions at the state and local levels. Oftentimes, a hospital may want to discharge the patient to a shelter only to discover that there are no available facilities in the area to take them. Or, they’ll seek post-acute care for that individual only to find few willing or able to accept patients in their socioeconomic condition.

Thus, hospitals were often left with little recourse but to discharge the patient to wherever they could. The law essentially takes that last-resort option off the table, leaving lots of facilities to completely reevaluate their approach.


The Solution


So, with resources strained and a homeless population that shows no signs of shrinking, what can hospitals do in order to meet the demands of the new law, fulfill their obligation to provide care and graduate patients to an appropriate level of care at a facility that better fits their circumstances? There are no easy answers, but there are a few guideposts administrators at hospitals we’ve worked with have used to steer the policy conversation.


  • Training

    Compassionate care of the homeless population starts with training team members on the unique challenges faced when discharging such individuals. Anyone at a hospital who comes into contact with homeless persons should be provided with coursework complete with in-person training and roleplaying exercises to ensure the patients’ needs are met.
  • Staffing

    It’s a good idea to have case managers available who specialize in addressing the needs of the homeless population and thus understand the challenges they face upon discharge.

  • Post-Acute Network

    Having a reliable, verified post-acute network is critical. You can’t begin the process of discharging large numbers of homeless patients unless your network of post-acute clinical and community-based services is current and complete. Facilities need to be thoroughly vetted with profiles that are updated regularly. Furthermore, post-acute networks shouldn’t be limited to traditional interpretations of medical facilities. In addition to rehab centers, home health services and nursing homes, a modern post-acute network should contain homeless shelters, community organizations, affordable housing and any other facilities a patient could conceivably go during their post-acute recovery.
  • Discharge Referral Software

    In addition to having an all-encompassing post-acute network, you also need a means of quickly and securely communicating with those facilities when you have a patient in need. That requires discharge software that instantly and seamlessly communicates your patient’s circumstances and can receive a ‘yes/no/considering’ response within minutes.
  • Follow-Up Care Management

    To prevent readmissions and ensure optimum care, you also need staff members who will follow up with patients and/or the providers overseeing their post-acute care. This is going to require a large expansion of communication between providers, but it’s absolutely essential, and it can be achieved through a coordinated investment in care management applications.

The Effect Goes Beyond California


The California law has had ramifications far beyond state lines. It has led health systems around the country to rethink how they approach the provision of healthcare to the homeless.

The guidelines I’ve offered here provide a way to frame the conversation and begin the hard work of creating policy that will aid that portion of our population most in need of assistance. By meeting this challenge head on, we can hopefully begin to ensure that everyone receives the absolute best care possible in both the short term and the long term.

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Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.