Bed rest for the weary

Mike Hamilton’s hands tell the story. His fingers are short and thick – too short, you realize – and it’s hard not to look at them and wonder what happened.

Back in December of 2009, Hamilton was clearing away snow for a place to camp, in a below-freezing wind chill. He’d lost his gloves. When he noticed, eventually, the blackening of his fingers, he tried without success to wash it off.

Eventually, he made it to the VA hospital. His recovery included two surgeries to remove his fingers and months of hospitalization – far more than a typical case might warrant – because he had nowhere to recover.

“They asked me where I could go,” he said. He shrugged. “Back on the streets.”

For the homeless, health care is often a journey between extremes: no care whatsoever or the most expensive care available, in the emergency room. Because they have no place in between, this becomes a cycle. They often struggle to recover from illness or injury or infection – don’t have a clean, warm place to change bandages or get low-level nursing care – and so they find themselves back in the ER for another expensive visit subsidized by taxpayers or the hospital.

“There’s a complete and utter gap in care,” said Jerry Schwab, assistant director of the House of Charity, a downtown Spokane shelter that provides food, beds and services to homeless men. “Our folks don’t have someone who they’re tethered to (like a primary care doctor). … The hospital is often their primary care physician.”

A Washington State University nursing student, in collaboration with the shelter and Providence Sacred Heart Medical Center, is trying to change that. Rebecca Doughty is developing a “respite care” program to provide homeless people a place to recover from illness and to receive some basic follow-up care. Modeled on successful programs in other cities, the idea is to keep homeless people out of the ER cycle, improving their health and saving money.

Doughty and the House of Charity are working out the details in a program that will bring a few hospital beds into the shelter. Doughty, who’s graduating with a master’s degree in nursing this May and entering a doctoral program, will provide the bulk of the care, helping men change bandages or get IV infusions. The House of Charity has beds for 108, but the men can’t generally stay there during the day. Women’s shelters also have limited hours.

“For patients that must rest in order to recover, being sent into the elements can be catastrophic,” Doughty wrote in a grant application for her program. “Homeless patients stay in the hospital an average of four days longer than non-homeless patients, due to lack of appropriate accommodations upon discharge.”

Doughty had her eyes opened to the particular health care needs of the homeless as an undergraduate, when she did some of her clinical work among Spokane’s downtown homeless people. She saw how the lack of primary care often resulted in preventable visits to the emergency room. She saw the reluctance of the homeless to get treatment before a crisis because they couldn’t pay or were wary of getting drawn into “the system.”

And she saw the ER problem in ways she hadn’t foreseen. For example, homeless men develop endocarditis – an infection around the heart that is common among drug users – and wind up in the ER for treatment. Recovery involves daily intravenous antibiotics for four to six weeks. Since many homeless people can’t – or won’t – return so consistently, hospitals tend to admit them for that entire period, at a cost exceeding $50,000, Doughty said.

“If we can put them into a bed where they’re getting their IV, it’s better for the hospital’s bottom line and better for the patients,” she said.

Doughty has secured enough funding to start small, with a few hospital beds upstairs at the shelter. In addition to Catholic Charities, she’s working with Providence’s Jeff Liles and Cathy McInroe to develop the program. Details are still to be worked through, in part because shelter officials have to figure out how the program fits with all the other work they do. Doughty is also seeking grant funding to expand and is eager to see it used in women’s shelters, as well.

Gene Howard is a 76-year-old homeless man who lives at the House of Charity. He said he’s seen a lot of homeless men cycling into and out of the ER. He considers himself fairly healthy but acknowledges he’s an alcoholic who treats illness with whiskey.

“It doesn’t cure any aches or pains, but you forget you have them,” he said. He uses a cane and suffers from numbness in his feet from an artery disease. He has no primary care physician.

“It’s just a matter of time until some health-related issue gets to him and he ends up in the hospital,” Schwab said.

And then, probably, just a matter of time until he’ll need to leave.