SB 1152 (Hernandez) - Discharge Planning for Patients Who Are Homeless
Patients’ Rights Advocacy Training
April 4, 2019
Sheree Lowe, VP Behavioral Health
(916) 552-7576, slowe@calhospital.org

Slide 2
Hospitals in California – Setting the Stage
400+ hospitals in California
–	GACH – General Acute Care Hospital – medical/surgical community hospital
–	Specialty – e.g., heart, eye, maternal, dental
–	APH – Acute Psychiatric Hospital
–	CDRH – Chemical Dependency Rehabilitation or Recovery Hospital
–	Other – e.g., State hospitals, Psychiatric Health Facilities (PHF)
Slide 3
Did You Know…?
–	Hospitals are NOT required to have an emergency department
–	There were more than 3 million inpatient discharges in 2017
–	There are more than 12 million emergency department visits annually
–	Hospital must provide a medical screening evaluation (MSE) to anyone requesting one (Federal law – EMTALA)
–	California has an estimated 134,000 people who are homeless – more than any other state and 25% of the nation’s total homeless population (estimated to be 500,000)
Slide 4
Homeless Patient Discharge
Reasons for homelessness are multi-faceted and complex
–	Broken families
–	Unmet behavioral health needs
–	Lost jobs
–	High cost of housing

Slide 5
Homeless Patient Discharge
Hospitals are committed to ensure anyone at a hospital receives:
–	Safe, medically appropriate care, regardless of life circumstances
–	Appropriate planning for discharge
–	Coordinated discharge to appropriate area shelters and other community-based services
–	A “warm handoff” (always the goal)
Slide 6
Homeless Patient Discharge
–	Patients who are homeless may choose to leave a hospital on their own terms, without accepting assistance
–	Individuals have the right to make their own decisions, and no organization can FORCE a person to accept help against his or her will.
Slide 7
New Guidebook: Discharge Planning for Homeless Patients
Image of Discharge Planning guidebook
CHA’s latest guidebook includes valuable checklists and sample forms, and:
–	Describes the required elements of a homeless patient discharge planning policy
–	Details how to implement the plan throughout the facility
–	Covers what to expect regarding enforcement
Slide 8
Introduction of SB 1152
–	Growing problem of patients who are homeless
–	Media reports
–	Limited ability to set the record straight due to medical privacy laws
–	Legislation – where we started and where we ended
–	Remember: Patients still have the right to leave against medical advice (AMA), elope, or refuse treatment

Slide 9
Which Hospitals Must Comply?
–	General acute care hospitals (GACH)
–	Acute psychiatric hospitals (APH)
–	Special hospitals (maternal/dental)
–	Not hospitals operated by the state of California (5 total)

Slide 10
Effective Date
–	Most provisions: January 1, 2019
–	Requirement for written plan to coordinate with community partners: July 1, 2019
–	Homeless patient log: July 1, 2019
Slide 11
Which Patients are Covered?
A homeless patient is an individual who:
–	Lacks a fixed and regular nighttime residence, or
–	Has a primary nighttime residence that is a supervised publicly – or privately – operated shelter designed to provide temporary living accommodations, or
Is residing in a public or private place that was not designed to provide temporary living accommodations or to be used as a sleeping accommodation for human beings?
Slide 12
3 Questions to Determine Homeless Status
Question One:
Do you have a primary nighttime residence that is supervised publicly or privately-operated shelter designed to provide temporary living accommodations?
–	If YES: Stop. The patient is considered “homeless” under the homeless patient discharge planning law.
–	If NO: continue to question 2

Slide 13
3 Questions to Determine Homeless Status
Question Two
Do you live in a public or private place that is not designed to provide temporary living accommodations or to be used as a sleeping accommodation for human beings? This could be a car, makeshift cardboard covering, etc.
–	If YES: Stop. The patient is considered “homeless” under the homeless patient discharge planning law.
–	If NO: continue to question 3
Slide 14
3 Questions to Determine Homeless Status
Question Three
Do you have a fixed and regular nighttime residence?
–	If NO: Stop. The patient is considered “homeless” under the homeless patient discharge planning law.
–	If YES: The patient is not considered homeless
Slide 15
Are These Patients Covered?
–	What about patients living in:
–	Car – homeless
–	RV – same spot or different spot
–	Domestic violence shelter – homeless
–	Friend’s couch 
–	Tent – sidewalk or permanent encampment
–	Law is not clear

Slide 16
Written Discharge Planning Policy
–	Since 2001, hospitals have been required to have written discharge planning policy
–	By Jan. 1, 2019, must add homeless patient discharge planning policy and process
–	9 new policy requirements

Slide 17
Where SB 1152 Started and Ended
Proposed
In order to discharge a patient:
–	Hydrated
–	Meal within 2 hours of discharge
–	Daylight only, and not during inclement weather
–	Prescriptions
–	DME – e.g., wheelchair, walker, cane
–	Vaccinations
–	Psych evaluation, if disoriented
–	Transportation

Now
In order to discharge a patient:
–	Meal
–	Weather-appropriate clothing/shoes
–	Discharge medications
–	Infectious disease screening
–	Referral, if possible
–	30 miles/30 minutes

Slide 18
Newly Required Elements of Written Policy
1.	Purpose of policy: “to help prepare homeless patient for return to community by connecting him or her with available community resources, treatment, shelter, and other supportive services”
2.	Ask patient about housing status; document answer
3.	Nondiscrimination provision: “Housing status will not be used to discriminate against a patient or prevent medically necessary care or hospital admission”
4.	Provide information about discharge to patient in a culturally competent manner (this is/was already required by law)

Slide 19
Newly Required Elements of Written Policy (cont.)
5.	An individual discharge plan must be prepared for each homeless patient
6.	“Discharge planning will be guided by the best interests of the homeless patient, his or her physical and mental condition, and his or her preferences for placement”
7.	How to identify a post-discharge destination for each patient (more on this later)
8.	Maintain homeless log (by July 1, 2019)

Slide 20
Newly Required Elements of Written Policy (cont.)
9.	Services that must be offered to the homeless patient prior to discharge:
–	Physical exam/determination of stability for discharge (already required by federal EMTALA laws)
–	Referral for follow-up care (medical, behavioral)
–	If follow-up behavioral health care is required, contact physical , health plan, mental health plan, or primary care provider or other provider, if applicable
–	Meal
–	Weather-appropriate clothing
Slide 21
Newly Required Elements of Written Policy (cont.)
9.	Services that must be offered to homeless patient prior to discharge (continued)
–	Discharge medications
–	Infectious disease screening
–	Vaccinations
–	Transportation (30 miles/minutes)
–	Screen/enroll in affordable coverage, if any
Note: Patient can decline offered services.
Slide 22
Identifying Post-Discharge Destination
Identify a destination:
1.	Social services agency, nonprofit social services provider, or governmental services provider that has agreed to accept the patient
–	Must document name of person who agreed to accept the patient
–	Must send written/electronic info about post-discharge health and behavioral health need
Slide 23
Identifying Post-Discharge Destination (cont.)
2.	Homeless patient’s “residence” – is “the location identified to the hospital by the patient as his or her principal dwelling place”
3.	An alternative destination as indicated by the homeless patient

Document well! Be prepared for “decline to state.”

Slide 24
Do Not Forget Current Law
Since 2008, it is illegal for a hospital to “cause the transfer” of a homeless patient to another county for the purpose of receiving supportive services from a social services agency, health care provider, or nonprofit social services provider in another county without that provider accepting the patient in advance.

Slide 25
Coordinating Services/Referrals with Community Partners
By July 1, 2019, hospitals must implement a written plan for coordinating services and referrals for homeless patients with available:
–	County behavioral health agency
–	Health care and social services agencies in the region
–	Other health care providers
–	Nonprofit social services providers
Slide 26
Coordination Plan
–	Must include a list of local homeless shelters
–	Hours of operation
–	Admission procedures/requirements
–	Population served
–	General scope of medical and behavioral health services available
–	Contact information for intake coordinator
–	Referral procedures
–	Training protocols for discharge planning staff
Slide 27
Questions?
THANK YOUI!
Sheree Lowe
VP Behavioral Health
(916) 552-7576
slowe@calhospital.org