Recuperative care is a critical component in the system of care that private hospitals depend upon to meet the needs of patients experiencing homelessness. Recuperative care is intended to provide medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets, but who are not ill enough to be hospitalized. In Los Angeles County, demand for recuperative care beds currently far outpaces supply due to record levels of homelessness, profound shortages in all forms of housing, and the requirements of Senate Bill 1152, California’s Homeless Patient Discharge Planning Law. As a result, private hospitals often experience challenges finding placements for their homeless patients, especially those with behavioral health comorbidities. In addition, private hospitals must bear the costs of recuperative care stays, which are currently not reimbursable by Medi-Care or Medi-Cal.
This Executive Summary presents key findings and recommendations to the UniHealth Foundation for ways to improve access to recuperative care for private hospitals and the homeless individuals they serve. These findings and recommendations are based on data gathered from interviews and analysis of administrative data from private hospital staff, recuperative care providers, two health plans that together provide coverage to most of the county’s homeless population and the Los Angeles County Department of Health Services (DHS) and is described in detail in the full report.
Recuperative care is impacted by shortages and challenges in the continuum of discharge settings.
The focus of this project was on recuperative care as a resource to meet patient and hospital needs. However, the findings drove home the point that recuperative care is impacted by the larger system of care for individuals experiencing homelessness of which it is a part, both in terms of health and housing needs. Currently, gaps in other parts of the system—most notably, transitional/bridge housing, shelters, PSH and to a certain degree, SNFs— all place additional pressure on recuperative care and affect the availability of resources experienced by hospitals.
There is no centralized access to information about recuperative care bed availability and few connections – formal or informal – among recuperative care providers.
While some agencies have informal connections to one another (typically through staff relationships) there is no central clearinghouse of information about bed availability in real time to streamline the process of locating beds when hospitals need them. It is not uncommon for hospital staff to call upwards of 20 recuperative care providers in order to find a single placement. This is time consuming and operationally inefficient, for both the hospital and patients who sometimes leave the hospital before a placement can be located.
Recuperative care providers are not always able to care for patients experiencing behavioral health issues in addition to their medical conditions.
Across agencies, leaders and discharge planning staff noted that only “a handful” of recuperative care agencies have the staff capacity to care for individuals experiencing severe symptoms of chronic mental health conditions in addition to medical conditions; estimates from DHS data suggest about 43% of beds are available to this population. As a result, the discharge planning process is inherently more complex for these individuals. Staff are not only charged with finding a bed, but rather finding a bed in the right facility at the right time.
Strong connections to the community-based systems of care serving homeless individuals can support discharge planning and relieve some stress on hospitals.
Discharge planners are tasked with meeting a wide variety of needs in addition to recuperative care for their patients experiencing homelessness. Some hospitals have homeless navigators (through partnerships or via training of internal staff) with specialized knowledge of homeless services. In the absence of this expertise, meeting the myriad of needs homeless individuals experience can be overwhelming for staff. Adding the identification of recuperative care on top, this is understandably stressful.
Per night costs feel burdensome to hospitals and lead to shorter lengths of stay.
The per night cost of recuperative care, while far less than an inpatient stay, continues to feel burdensome for hospitals; in large part because it is not covered at all by Medi-Cal. This, in turn, limits the lengths of stay they can support as evidenced in the data. While the current length of stay in county-funded recuperative care beds is about 9 months (at approximately $190 per night), current stays in privately funded beds cost between $225-$250 per night; subsequently stays average closer to 14 days and rarely exceed 30 days. Some stakeholders believe a shared cost/pooled resource model could reduce costs for private hospitals.
Homeless individuals’ needs, preferences and sense of trust with hospital staff impact their willingness to accept and remain in a recuperative care placement.
Hospital discharge placement data shows that individuals often refuse placements in recuperative care. In cases where the reason for refusal is known, people most frequently decline services because they do not want to be transported to a facility outside of their home community. Hospital staff also noted the importance of trust in the discharge planning process. Although staff begin discharge placement planning as early as possible during the stay, given most stays are short, there may not be enough time for the intense trust building that is often required for homeless individuals to feel comfortable enough to accept a placement, whether in recuperative care or elsewhere.
Recommended Strategies to Support Hospitals and Strengthen Systems
Recommendations are presented on a continuum, beginning with those that could be most directly implemented by the Foundation with minimal support from other systems players. These are followed by strategies that require more intensive investment by the Foundation and/or involve more players to implement. The final category of recommendations speak to systems change efforts that, while more distal from the private hospitals that the Foundation serves, have the potential to strengthen the system in meaningful ways that would ultimately benefit private hospitals.
Build Resource Knowledge and Strengthen Relationships
- Strengthen understanding of DHS programs and foster collaborative relationships between DHS and private hospitals. There are fundamental disconnects between private hospitals and DHS, what has resulted in a myriad of misunderstandings about the availability of DHS resources to private hospitals. UniHealth Foundation is uniquely positioned to convene DHS, private hospital care coordinators and recuperative care enrollment specialists to build more productive working relationships by creating a space to share information and foster empathy for one another’s work.
- Support hospitals to integrate homeless navigators into their Emergency Departments. UniHealth Foundation has already invested in a pilot effort to embed housing navigators in medical settings in the San Gabriel Valley. This work could be replicated to support hospitals throughout LA County. Promising models exist, including the Kaiser Permanente Los Angeles Medical Center/JWCH model.
- Provide enhanced training about resources for homeless individuals to discharge planners/care coordinators. Hospitals would benefit from UniHealth Foundation’s support to enhance staff knowledge of resources to meet the needs of their homeless patients. High quality training is readily available, via resources such as LAHSA’s online Centralized Training Academy, but hospitals could use financial support to cover staff time to participate in training and enrollment fees.
Address Systems Gaps
- Fund a technology platform to streamline placements and enhance patient data. Access to real-time information about recuperative care bed availability that can be linked to electronic medical records would streamline the placement process and provide meaningful, cohesive data about patient outcomes.
- Subsidize the cost of recuperative care for private hospitals to extend lengths of stay. Private hospitals reported paying $225-$250 per night for recuperative care; in comparison, DHS pays an average of $150 per night. Subsequently, most hospital funded stays are between 10-14 nights, and stays longer than 30 nights are rare. Subsidizing some of the cost of recuperative care might allow private hospitals to offer longer stays, allowing patients more time to connect with housing resources and receive other wrap around services that would increase the likelihood of moving out of homelessness; or if qualified, moving into the Housing for Health programs.
- Continue to fund housing solutions. Recuperative care is intended to meet a medical need, but in the LA homeless context, it is increasingly being used to also address housing needs. In the absence of adequate housing options, retaining individuals in recuperative care prevents them from returning to the streets and provides opportunities to address behavioral health issues, enhance life skills and access sources of income. This strategy could create sustainable change in Los Angeles County and is in-step with national innovations.31
- Ensure Board and Care facilities are preserved via adequate reimbursement. The continued loss of Board and Care facilities in Los Angeles County would likely create a massive inflow of new homeless, further burdening hospitals and the health care system. UniHealth Foundation should continue to fund advocacy for enhanced reimbursement rates to ensure long-term sustainability and in the interim might consider time-limited financial support to providers at risk of closure.
- Improve access to SNF care through partnerships with recuperative care providers. Some SNFs lack the capacity to address the complex discharge planning needs of homeless patients, which can result in reluctance to provide care for them. There is evidence of innovative partnerships between recuperative care providers and SNFs that could be more widely spread to increase SNF willingness to serve homeless patients.
Support Policy and Advocacy Work
- Fund advocacy efforts to include recuperative care reimbursement in Cal AIM. There are a number of nonprofits and membership organizations that are working in advocacy for reimbursement reform under Cal AIM. Recuperative care is one potential reimbursement that, if included in the reform, would provide a significant new revenue stream for recuperative care.
- Create a streamlined system of pooled funding and shared recuperative care beds among private hospitals. Private hospitals see the value in pooled funding and shared beds to make better use of limited existing resources. As a trusted leader, UniHealth Foundation can bring hospitals together to create the necessary agreements and infrastructure needed for this model.