1. Kritz, Fran


Nurse-led transitional care may be one solution.


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Despite a 1986 federal law aimed at preventing "patient dumping"-which is a failure to screen, treat, or appropriately transfer patients-some hospitals and nursing homes continue to push people out the door when they are unable to pay for care. Notable recent occurrences include an episode in 2017, in which a woman with no health insurance who sought care at Howard University Hospital in Washington, DC, was instead pushed in a wheelchair by campus police officers to a bus stop. In the incident, which was recorded on camera and reported widely, an officer stopped the wheelchair abruptly, causing the woman to fall to the ground. She was then left there, dressed only in a hospital gown and socks.

Figure. A homeless m... - Click to enlarge in new window A homeless man, still in his hospital gown, wanders downtown Los Angeles after being "dumped" by a nearby hospital. The problem of patient dumping got so bad, said the Reverend Andy Bales, chief executive officer of Union Rescue Mission, a local shelter, that they had to set up a video camera to record it. Photo by Rev. Andy Bales.

In January, a woman whose family said she had been struggling intensely with mental illness, was treated at the University of Maryland Medical Center in Baltimore. Afterward, she was escorted by security officers to a bus stop at night, when the temperature was in the 30s. Although the hospital says the woman received treatment-and thus this was not technically a case of patient dumping-the woman's family said the care was clearly not enough. The patient was dressed only in a hospital gown and socks when she was released, and a video shot by a passerby shows that she had a head injury and was disoriented at the bus stop.



The 1986 Emergency Medical Treatment and Labor Act (EMTALA) requires that hospitals screen patients who seek emergency care. If a patient is found to have an emergency medical condition, the hospital must then either stabilize or transfer the patient, regardless of health insurance status or the person's ability to pay. After the patient's condition is stabilized, however, the hospital can release the patient, even if she or he has nowhere to go, says Miriam Ricanne Swedlow, JD, RN, an administrative law attorney based in Seattle.


Recent changes in Medicare payment rules, which were initiated by the passage of the Affordable Care Act, penalize hospitals for readmissions that occur within 30 days of discharge. This should lead to changes in discharge planning, even for patients who are discharged back to the street or to a homeless shelter, says Jennifer Mensik, PhD, RN, NEA-BC, FAAN, an instructor at Arizona State University's College of Nursing and Health Innovation in Phoenix and the division director of care management at Oregon Health and Science University Healthcare in Portland.


A 2014 report by the U.S. Commission on Civil Rights noted that the passage of EMTALA had failed to curtail patient dumping. It called for additional policies and procedures to ensure better data collection and regulatory oversight as well as the establishment of best practices and discharge protocols. Yet the office has no enforcement authority, admits Brian Walch, the agency's director of communications and public engagement.


In recent position papers, professional nursing associations have focused on transition management. The American Organization of Nurse Executives (AONE) and the American Academy of Ambulatory Care Nursing issued a joint statement in 2015, outlining how nurse leaders working in inpatient and postacute or outpatient settings could enhance the coordination of care and transitions while advocating the value of nursing, says Geralyn Randazzo, MS, RN, NEA-BC, an AONE board member and vice president of care management at Northwell Health in Great Neck, New York. In May of that same year, the American Nurses Association (ANA) released its Policy Agenda for Nurse-Led Care Coordination, which offered a "blueprint for policy action" aimed at enabling nurses to provide "outstanding care coordination."


Liz Stokes, JD, RN, director of the ANA Center for Ethics and Human Rights, notes that "nurses work on a team-we're not in a silo and cannot solve [the problem] on our own." But nurses can and do have the opportunity to assess a patient's care coordination and risk assessment, and they can identify the potential for poor outcomes if the patient is discharged or transferred inappropriately. "In some facilities, it's always a nurse who helps decide on admission and discharge, and in others it's not. It's important to always have nurses be part of the conversation," says Stokes.


Nurses must also be aware of the standard of care, says Swedlow. "Hospitals have regular training to educate and update health care staff on their professional and legal responsibilities to patients." In her clinical experience, nurses already see their role as encompassing discharge care planning. "Nurses who have been in the field instinctively want to help their patients get and stay healthy, and that-more than any law-is what should and does drive nurses."


Randazzo thinks a key challenge to reducing the incidence of patient dumping is to pay more attention to the social determinants of health and how they affect the patient's ability to transition to care outside of the hospital. She noted that 2018 was declared by the ANA to be a "year of advocacy"-with an emphasis on designing solutions for problems that most often affect the most vulnerable patients. "In the hospital, 80% of a patient's time is spent with nurses," says Randazzo. "That puts nurses in a great position to lead some of the change moving forward."


The report from the U.S. Commission on Civil Rights recommended the development and dissemination of best practices-something an increasing number of nurse leaders are doing regularly. Randazzo, for example, frequently speaks at conferences on behalf of AONE and shares information about what hospitals are doing to improve transitions of care. She also describes how Northwell Health facilitates discharge for uninsured patients by bringing financial counselors to the bedside; they offer fees on a sliding scale based on income and, if applicable, Medicaid applications and assistance completing them. Nurses and other hospital staff help patients connect with housing, food sources, job placement, community clinics, and other needed services.



Because nurses frequently gain patients' trust quickly, they are positioned to help patients engage with the services they need. To do so, nurses must be familiar with resources in their communities, such as after-hours clinics, so that patients are discharged with this information. Teri Dreher, RN, CCRN, chief executive officer of NShore Patient Advocates in Chicago, recommends that care management staff visit any community resources they recommend to patients. Yet she points out that many patients don't read the discharge information. Innovations at some hospitals seek to address this. In her care management role, for instance, Mensik employs health workers who follow up with all patients, including those who are homeless, within a day or two of discharge to help them access resources.


The opioid crisis is adding to concerns about patient dumping, says Mensik. Many rehabilitation and skilled nursing facilities will not accept patients with substance use disorders, even though these patients often desperately need a place to recover from infections or illnesses linked to their drug use. There are concerns the facility might be held liable, for example, if patients use iv lines for illegal drug use, she says. "But nurses can intervene to advocate for these patients to be accepted by a facility," Mensik continues. "They may not be ready to stop using drugs, but they might be ready to access housing, food resources, or other services. Our job as nurses is to help patients see there are possibilities and to teach the community how to care for them."


Nurses can also advocate for patients by sharing their stories with city councils and state legislatures, says Mensik. Stories about patients who are homeless but must be discharged have much more impact than charts and graphs, she points out.


"The hospital can't fix every social issue of a patient; we must rely on our postacute agencies to help bridge those gaps," says Mensik. "That's why discharge planning should start when a patient is admitted to the hospital instead of waiting until the last day. Nobody should be rolled into the street."-Fran Kritz