Discharge Planning for a Homeless Patient with Complex Needs
Ms. T, a 45-year-old woman with diabetes and a below-knee amputation, is ready for discharge from a rehabilitation facility. She is homeless and has no family support. She has Medicaid and receives $200/month in general assistance. She needs wound care, insulin, and physical therapy. The facility's discharge planner must arrange housing, follow-up, and medications. The local shelter does not allow medications or wound care supplies. Ms. T is eager to leave but has limited insight into her needs.
1. What are the key challenges in discharge planning for Ms. T, and how should the administrator prioritize them?
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Key challenges: lack of stable housing, limited income, need for ongoing wound care and insulin, and limited insight. Prioritize immediate safety: housing that accommodates medical needs (e.g., medical respite program, transitional housing). If unavailable, consider a short-term skilled nursing facility stay while seeking housing. Ensure medications are affordable (generic, patient assistance programs) and accessible (e.g., pharmacy delivery). Arrange wound care through a home health agency or outpatient clinic. Physical therapy can be continued at a community clinic. The administrator should coordinate with social work, case management, and community resources. Involve Ms. T in planning to the extent possible, using motivational interviewing to address insight.
2. How can the administrator advocate for Ms. T at the systems level?
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The administrator can advocate for policies that fund medical respite programs and supportive housing. They can also work with local shelters to allow medications and supplies, or create a partnership with a harm-reduction approach. At the facility level, they can develop a protocol for discharging homeless patients that includes a warm handoff to community providers and a follow-up call within 48 hours. They can also engage in community planning coalitions to address gaps in services. Documenting Ms. T's case (with consent) as an example of system gaps can support advocacy efforts.