In Seattle, there's a place--and it costs much less. Cities around the country are looking to programs like Seattle's as a model.
For decades, Edward Thomas was hard to help. He slept on a mat in the Downtown Emergency Services Center’s main homeless shelter. He came in late and left early, muttering to himself, his legs so swollen he could wear only Velcro-strapped cast boots, his doctor said.
Thomas’ elephantiasis got so bad it caused open wounds on his legs, landing him in the hospital for seven weeks. His doctors couldn’t send him back to the shelter in good conscience; his legs were leaking fluid into his socks.
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So the doctors tried something new.
They moved him into a medical respite in the Salvation Army shelter in the International District — a few beds with nurses on staff. They gave Thomas headphones and music to listen to. He got comfortable, and finally met with a mental-health caseworker. He got antipsychotic meds. He got into housing, and never went back to the shelter.
As homelessness continues to rise in Washington, patients like Thomas present a worsening problem for public hospitals. Hospitals are required by federal law to treat patients regardless of their ability to pay, but many chronically homeless people have overlapping medical and mental struggles that make them ethically difficult to discharge.
The problem is serious enough that Washington State Hospital Association convened a work group from area hospitals: They found that in Western Washington during summer 2018, there were 200 homeless patients who spent an average of 82 days in the hospital after they no longer needed acute inpatient care.
When homeless people do get released, their issues combined with living on the street will usually land them back in emergency rooms, costing hospitals like Harborview Medical Center — which operates on a thin margin — time and money.
“Some patients come to the hospital ER a hundred times a year, or more,” said Cassie Sauer, president of the WSHA. “A volume that you and I can’t fathom.”
One solution is the type of respite program Thomas benefited from, providing short-term care to homeless patients who are too sick to be on the streets or in a shelter, but not sick enough to continue to take up a hospital bed. Thomas proved such a success that, when the respite program moved in 2011 across the street from Harborview’s emergency room, the planning committee named it the Edward Thomas House. A photo of his face greets patients as they enter today.
In the Edward Thomas House, it costs $400 a day per person. Across the street at Harborview, it’s around $2,000 a day. And time spent in respite care reduces future time in the hospital: A 2006 study of a Chicago hospital found the average homeless person who had respite care spent 3.7 days in the hospital in one year; the average homeless person who didn’t spent 8.3 days.
National studies show medical respite decreases future hospital stays for the homeless people who come through, cutting costs for hospitals and the government. In Arizona, one study showed a Phoenix respite saved Medicare and Medicaid $1,320 per patient per month, reducing costs by 58 percent and saving more than $4.7 million in care for the 309 patients who participated in the study.
Medical respites can also hold hospitals accountable for making sure they discharge people to a safe place, according to Julia Dobbins, who works as a liaison for the National Health Care for the Homeless Council to respite-care providers. Discharging a vulnerable patient can turn into a PR nightmare for a hospital: Last winter, video of a homeless woman left outside a Baltimore hospital in her socks and a hospital gown went viral; other instances of “homeless dumping” have kicked up outrage across the country.
“We’re making sure they don’t come back to the hospital for the reason they came in the first place,” Dobbins said.
Inside respite
Edward Thomas House doesn’t feel like a house so much as a clinic; It’s a floor in Jefferson Terrace, Seattle Housing Authority’s largest apartment building, across the street from the ambulance entrance of Harborview.
There’s a lounge with an electric keyboard and a bookshelf, exam rooms with views of Smith Tower and First Hill, and three-person rooms with privacy curtains and containers. Some of the beds are unmade, with clothes or food strewn around; others are meticulously clean and well-kept.
There are, of course, limits to the program. It’s not a nursing home, and there is no bedside care. People must be able to walk or operate a wheelchair. They can stay for a maximum of three months (the average stay is around three weeks, according to staff), and sex offenders are not accepted.
Drug use is not allowed on the property, but the program won’t refuse care to someone they know is using drugs; social workers at respite can connect people to everything from drug treatment to eye care.
Programs like the Edward Thomas House, or its shelter-based predecessor, started in the 1980s but have grown in the last decade to around 80 facilities nationwide.
Washington has four — besides Seattle there’s one in Yakima, one in Spokane, and one that opened in September in Bremerton — which is more than any other state except California, according to the National Healthcare for the Homeless Network’s directory. Seattle’s is one of the larger ones in the country, with 34 beds that stretch to 35 when demand is especially high.
A lot of respite care’s utility is — for lack of a better word — “capturing” a homeless person, according to Dr. Leslie Enzian, the medical director at the Edward Thomas House and Edward Thomas’ doctor for years.
“I can’t tell you how often I ask someone who their emergency contact would be and they have not one person in the world,” said Enzian. “Often their community is a community of people who are drinking alcohol or using drugs and that’s really the only support network they have.”
Two hospital visits, two different outcomes
One night in 2014, Tasha Webb signed herself out of Harborview with nowhere to go, so she rolled her wheelchair down the hill to a shelter downtown. She’d been in a car accident, had a broken hip and ankle, and Webb said she had only recently become homeless after running from her husband.
She had no money for therapy; her hip and ankle healed wrong. She became addicted to heroin she used to deal with the pain. Today she walks with a cane and lives in an unsanctioned tent camp in Georgetown. Two months ago, she landed in the hospital again after she got an abscess from a heroin needle. She was admitted to Swedish.
This time, instead of rolling herself out of the hospital, Webb went to Edward Thomas House, where she had her own little corner with a small window. She got a kidney biopsy. She got on methadone. It’s the fourth time Webb has been in treatment, but she feels this hospitalization has scared her straight.
“It was actually kind of a blessing because it got me help,” Webb said. “I had never been so sick from a stupid mistake. I’m trying to get off the stuff.”
This month, she was discharged and went back to her camp in Georgetown. It’s cold, rainy and wet, she says. But despite the 45-minute bus ride to the treatment center every day, so far “the fear of being sick is enough motivation” to stay on methadone.
But on the streets, fears compete with each other. Webb is scared, for instance, of getting the results of her kidney biopsy back — but worse is the fear of what will happen if she stays in a tent outside.
“Maybe I’ll be fast-tracked to get housing if there’s something wrong,” Webb said in an email. “That’s awful to think but it’s true.”