Establishing Characteristics for Unsheltered Older Adults Who Experience Unplanned Hospitalization Visits After Being Discharged from the Hospital to the Street or Temporary Housing

More than 3000 Utahans and over half a million people in the United States experience homelessness. Those who experience homelessness for extended periods are more likely to live shorter lives with lower quality of life. Studies show that when persons who have experienced homelessness are discharged from the hospital to the street, they are more likely to experience a relapse in medical symptoms, fall, or fail to adhere to the proper medication schedule, which can lead to increased pain levels, worsening physical health, and other conditions requiring rehospitalization.

1 MS Project: Establishing Characteristics for Unsheltered Older Adults Who Experience Unplanned Hospitalization Visits After Being Discharged from the Hospital to the Street or Temporary Housing by Jaime Cross The University of Utah, College of Nursing, Gerontology Interdisciplinary Program Master's Project April 22, 2024 Supervisory Committee: Linda S. Edelman, RN, Ph.D., FGSA, FAAN (Chair) Caroline Stephens, Ph.D., GNP, FAAN Brenda Luther, Ph.D., RN 2 Abstract More than 3000 Utahans and over half a million people in the United States experience homelessness. Those who experience homelessness for extended periods are more likely to live shorter lives with lower quality of life. Studies show that when persons who have experienced homelessness are discharged from the hospital to the street, they are more likely to experience a relapse in medical symptoms, fall, or fail to adhere to the proper medication schedule, which can lead to increased pain levels, worsening physical health, and other conditions requiring rehospitalization. Purpose/Aims. The purpose of this student-led project was to identify demographic, social, and health characteristics of unsheltered older adults who experience unplanned hospitalizations after being discharged from the hospital to the street or temporary housing before admission to The Inn Between (TIB), a hospice and medical respite care facility for adults who have experienced homelessness. The Andersen Behavioral Model guided the project to improve our understanding of the key factors driving these rehospitalizations. The specific aims were to: 1) identify demographic and health characteristics associated with rehospitalization through a medical record review of TIB residents discharged from a hospital to the street or temporary housing before being admitted to TIB within the fiscal year between July 1, 2022, and June 30, 2023; 2) conduct focus groups or semi-structured interviews with TIB administration, staff, and hospital employees to learn their perceptions of factors associated with unplanned rehospitalizations from individuals discharged from the hospital to the street or temporary housing before admission to TIB; and 3) draft an infographic for the TIB to use when education hospital staff. 3 Methods. For Aim 1, demographic, social, and health history data were collected from the resident’s medical record data. Descriptive statistics (t-tests and chi-square analyses) were used to describe differences between individuals not directly admitted and those rehospitalized. For Aim 2, interviews or focus groups with TIB administration (n=5) and a hospital employee (n=1) were conducted, recorded, and transcribed. Qualitative descriptive data analysis was used to identify perceived factors contributing to unplanned rehospitalizations. Results. Between July 1, 2022, and June 30, 2023, 72 individuals were discharged from a hospital to the street or temporary housing before admission to TIB. Eleven (15.3%) individuals were readmitted to the hospital within three weeks of admission to TIB. Of these 11 individuals, 14 hospital readmissions occurred. Residents who were readmitted to the hospital were more likely to be male (90.9% compared to 73.8%), younger than those not readmitted (49.6 years compared to 56.4 years), and more likely to have been homeless for a week or more, but less than one month (50.0% compared to 18.6%). The focus group and the interview found three overarching themes associated with unplanned rehospitalizations: medical, personal, and resources. Conclusions. By improving our understanding of unplanned rehospitalizations for individuals who were discharged from the street or temporary housing before admission to TIB, hospice/medical respite facilities can educate hospitals on the characteristics of those who are more at risk of rehospitalization to encourage consideration of other discharge options. The next steps in this work include gaining residents’ perspectives and reviewing hospital records to gain further insights into unplanned hospitalizations in this vulnerable population. 4 Background At the beginning of 2020, 580,466 people experienced homelessness in the United States and 3,131 people in Utah alone (National Alliance to End Homelessness, 2020). Many factors can lead a person to lose the roof over their head, including inflation, job loss, significant life changes, and healthcare costs (Alamu et al., 2022). Older adults with fixed incomes are more susceptible to homelessness due to unexpected expenses and increases in costs without income increases. For example, when rent, food, gas, and other services increase without an increase in revenue, individuals must consider the money available to spend on necessities, including healthcare. This could mean they opt not to refill medications to afford food or shelter. When they cannot afford shelter, the risk of facing homelessness increases. Older adults experiencing homelessness are more likely to be experiencing one or more other hardships as well, such as mental illness, poorer physical health, and lack of social connectedness (Alamu et al., 2022). Persons experiencing homelessness are also at a higher risk for communicable diseases and other chronic conditions, such as heart disease and diabetes (Cha et al., 2021; Mira et al., 2022), and those diagnosed with cancer are often unable to receive treatments without a permanent address associated with their name (Asgary, 2018). Unmet healthcare needs can increase the risk of emergency room visits and hospitalizations (Cha et al., 2021). Lack of adequate follow-up care after hospital discharge often leads to rehospitalization or even death (Subedi et al., 2022). Thousands of persons who experience homelessness across the United States die each year (Kleinman et al., 2022). The causes behind these deaths vary greatly, and some deaths are left unexplained and unreported (Kleinman et al., 2022). Persons experiencing chronic homelessness are more likely to live shorter lives than those who are housed (Jayawardana, 2020). A study in Europe found that life expectancies for people experiencing chronic 5 homelessness are 43 years for women and 45 years for men (Cha et al., 2021). These numbers are much lower than the life expectancies reported for individuals not facing homelessness (76 years for men and 81 years for women) (Burns et al., 2018). There are several reasons for decreased life expectancies for adults who experience homelessness. They often do not have proper healthcare available to them, including much-needed physical evaluations and mental health consultations (Cha et al., 2021). Those sleeping in tents or on the street frequently endure rough sleeping because of weather, foot and car traffic, and the chance of being attacked, which takes a toll on their overall health (Cha et al., 2021). Substance abuse is commonly associated with persons experiencing homelessness (Tong et al., 2019). These factors can result in poor health in the mid-stages of their life, meaning that they can be functionally old at a younger age. Care facilities for this marginalized population are few and far between, but they can improve quality of life by providing evidence-based care interventions for individual needs (Biederman et al., 2019). Medical respite is offered to persons who experience homelessness and who are either terminally ill or too sick to be on the street but too well to be in the hospital. For example, people who live on the street experience rough conditions that can make wound care or medication consistency difficult. Such facilities provide a safe space while the individual recovers and is well enough to be independent again. The Inn Between (TIB) Hospice Center for the homeless in Salt Lake City, Utah initially opened in 2015 in an old Roman Catholic Convent and has since moved into a formal care facility with a total of 50 beds separated equally by type II assisted living and independent living for adults 18 and older who have experienced chronic homelessness. It is the only end-of-life care service for homeless adults in the Salt Lake area of Utah (The Inn Between, 2023). TIB also 6 provides medical respite for those who need a permanent address to receive treatments like radiation for cancer or wound care. TIB’s mission is to create a safe environment that protects and preserves the health and dignity of the people they serve. TIB provides medical respite for people discharged from the hospital who do not have a permanent address to reside in while recovering. When admitting a new resident, TIB needs at least 24-hour notice to prepare the resources each resident needs and finalize the intake process. Therefore, TIB cannot always admit someone directly from the hospital. The patient’s intake form needs to be completed, TIB’s nurse must do a medical assessment, and a bed must be available. When TIB cannot take the patient directly from the hospital, the patient may be discharged to the street or temporary housing before their admission to TIB. Discharge to the street or temporary housing increases the individual’s risk of new, or worsening of current conditions, before admission to TIB. This gap in the required follow-up care increases the risk of unplanned hospital readmission shortly after admission to TIB. TIB is committed to decreasing the number of unplanned hospital readmissions for residents who were discharged from a hospital to the street or temporary housing before admission to TIB. TIB administration perceives that time spent on the street or in temporary housing causes an interruption in recovery from patients’ medical conditions. Patients discharged to the street may be more likely to experience a relapse in the condition for which they were initially hospitalized, fall, or are unable to adhere to the proper medication schedule, which can lead to increased pain levels or worsening of chronic conditions (Merdsoy et al., 2020). Unplanned readmissions are hard for residents and are expensive. TIB has not recorded the cost of unplanned readmissions. However, a 2023 study in England found that unplanned hospital 7 readmissions from those experiencing homelessness can cost upwards of 5,000 British Pounds, equivalent to over $6,000 U.S. (Tinelli et al., 2023). Project Purpose The purpose of this project was to describe characteristics of unsheltered older adults who were discharged from the hospital to the street or temporary housing before admission to TIB and experienced unplanned rehospitalizations within three weeks of admission. Unplanned rehospitalizations in this project were defined as hospital admission within three weeks of admission to TIB. The aims of this project were to: 1. Identify demographic and health characteristics associated with unplanned rehospitalization within three weeks for persons who were discharged from a hospital to the street or temporary housing before admission to TIB. 2. Conduct semi-structured interviews or focus groups with TIB administration, staff, and hospital employees who experienced unplanned rehospitalization after admission to TIB from the street or temporary housing to learn about their perceptions of factors associated with unplanned rehospitalizations. 3. Develop a draft of an infographic based on the findings, that TIB staff can use to educate referring hospitals about factors associated with unplanned hospitalizations after patients were discharged to the street or temporary housing before admission to TIB. Theoretical Framework This project was guided by the Andersen Behavioral Model (ABM) of Health Service Use to help identify the predisposing, enabling, and need factors associated with unplanned rehospitalizations after being discharged from the hospital to the streets or temporary housing 8 before being admitted to TIB (Brettel et al., 2022). This model has been widely used to understand a population’s relationship with and utilization of healthcare (Hajek et al., 2021). Predisposing factors are individual characteristics, such as demographics, social structure, and attitudes/beliefs (Gelberg et al., 2000). Predisposing factors in this project included age, race, ethnicity, gender, sexual orientation, marital status, religion, and victim of domestic violence. Enabling factors are conditions or resources that hinder or enable healthcare utilization (Gelberg et al., 2000). Enabling factors in this project included insurance(s), income, percent area median income (AMI), if the resident had any benefits, such as Supplemental Nutrition Assistance Program (SNAP), the quarter of the fiscal year in which they were admitted to TIB, housing status, housing category, length of stay in prior living situation, months homeless, number of times homeless in the past three years, city of residence, veteran status, and if they were stable per Homeless Management Information Systems (HMIS) guidelines. Need factors are the most proximal to service use and include a person’s perceived and evaluated functional capacity, symptoms, and health status (Gelberg et al., 2000). Need factors in this project included the type of care program they were admitted to at TIB, whether persons had disabling conditions, used a wheelchair, had a physical or developmental disability, or were diagnosed with HIV, mental health, alcohol abuse, drug abuse, chronic health conditions, or cancer. The medical category, defined as the medical reason for receiving treatment at TIB, was also included. Predisposing, enabling, and needs factors were assessed for each resident discharged to the street or temporary housing prior to admission to TIB. Factors associated with unplanned rehospitalization were identified and used to draft an infographic to educate referring hospital staff about the risk of rehospitalization when individuals are discharged to the street or temporary housing. 9 Method This quality improvement project utilized retrospective quantitative medical record data and qualitative focus group and interview data from TIB staff and a hospital employee to help identify factors associated with increased risk of rehospitalization after being discharged from a hospital to the street or temporary housing before admission to TIB. Institutional Review Board Approval The University of Utah Institutional Review Board reviewed the project and deemed it Minimal Risk. TIB resident data were deidentified. Interview and focus group participants provided verbal consent for the focus group and interviews to be recorded and transcribed. Setting and Sample TIB serves adults 18 and older who are experiencing homelessness and are either terminally ill or too sick to be on the street but too well to be in the hospital. TIB population tends to be younger than the typical hospice patient; however, TIB residents younger than 50 are often functionally older and receiving end-of-life care. The sample for Aim 1 was a retrospective medical record review of TIB residents admitted between July 1, 2022, and June 30, 2023, who were discharged from the hospital to the street or temporary housing before they were admitted to TIB. The sample for Aim 2 was TIB administration who participated in a focus group. Participants provided nursing, admission, nursing, hospice, and administrative perspectives on why TIB residents who are admitted to TIB from the street after a hospitalization are more likely to be rehospitalized. A hospital case manager was interviewed to provide a perspective of why patients are discharged to the street or temporary housing instead of waiting until the patient can be admitted to TIB. 10 Data Collection and Analysis Aim 1: Retrospective medical record data Medical record data from residents admitted to TIB between July 1, 2022, and June 30, 2023, were searched to identify all residents who were discharged from a hospital to the street or temporary housing before TIB admission. The final sample included retrospective data from 72 residents. Medical record data as recorded in TIB’s annual report and other data sources, such as the Utah Homeless Management Information System (HMIS) and case notes, were searched to identify which of the 72 residents were readmitted to the hospital within three weeks of admission. If information was not found in those locations, TIB’s Microsoft Teams channel was searched for messages regarding residents utilizing ambulance services or being readmitted to a hospital. Eight of the eleven residents who were readmitted to the hospital within three weeks of admission were identified this way. Data variables were described by components of the Andersen Behavioral Model Framework: Predisposing, Enabling, and Need factors (see Table 1). Predisposing Factors. Demographic characteristics included age, race, ethnicity, gender, marital status, sexual orientation, and religion. History of domestic violence included if an individual was a victim of domestic violence, if they were still fleeing, and how long it had been since they last experienced it. Enabling Factors. Insurance status included personal insurance, Medicare, Medicaid, etc. Income included income upon entrance to TIB and annual income. Percent area median income (AMI) was defined by the area median income in Salt Lake City, which was $106,000 for families of four (Salt Lake County, 2022). AMI was categorized as 50% below the median 11 for very low income or less than 30% of the median for extremely low income. Any income under $14,580 annually for an individual in Salt Lake County was considered below poverty in 2022 (Salt Lake County, 2022). Entry benefits from any source were any additional assistance for daily necessities, like nutrition assistance programs. Veteran status was determined by whether the individual was a military veteran or not. TIB admit quarters between July 1, 2022, and June 30, 2023, were quarter 1, July through September; quarter two, October through December; quarter three, January through March; and quarter four, April through June. Housing history included whether the individual was in a homeless living situation before TIB admission, such as a shelter or street, a temporary living situation like with a friend or in a motel, an institutional setting like a hospital or skilled nursing facility, and a permanent setting like owning or renting a space to reside. Housing status was further defined as staying in a shelter, hospital, motel, or apartment. Data on whether the individual was chronically experiencing homelessness and the number of times they were homeless in the last three years were also collected. Chronically homeless was defined as the individual experienced homelessness for at least a year or experienced homelessness at least four times in three years. The length of stay in the resident’s prior living situation was the amount of time that individual was residing in the place they were staying prior to admission at TIB. The number of months they were homeless was measured by how long they were homeless before admission to TIB. Stable per HMIS guidelines indicated that the individual was evaluated as self-sufficient and able to secure housing. Need Factors. Health status included the individual’s medical history, intake program at TIB, disabling conditions, developmental disabilities, physical disabilities, chronic health conditions, mental illness, HIV, cancer, and if they used a wheelchair for mobility. Intake 12 programs at TIB were categorized as medical respite (MR) or end-of-life (EOL) services like hospice or palliative care. Disabling conditions were conditions related to the individual's physical and mental state that kept them from working and obtaining housing. Developmental disability was defined as a delay or impairment in development that altered an individual’s ability to learn or manage behaviors. History of substance abuse, including alcohol and drug abuse, was defined by whether the resident had a dependency on alcohol or other drug substances and over-consumed drugs or alcohol frequently. The medical category further defined medical conditions requiring treatment from TIB. This included recuperative care, surgery recovery, wound care, etc. Table 1 Andersen Behavioral Model Identifying Factors Predisposing Factors Age Sexual Orientation Race Marital Status Ethnicity Victim of Domestic Violence Gender Enabling Factors 13 Insurance Housing Status Income Housing Category Percent AMI Months Homeless Entry Benefits from Any Source Number of Times Homeless in Last 3 Years Residing City Length of Stay in Prior Living Situation Veteran Status Stable per HMIS Need Factors TIB Program (Medical Respite or EOL) Developmental Disability Disabling Condition Physical Disability Chronic Conditions HIV Wheelchair Cancer Medical Category Alcohol Abuse History of Mental Illness Drug Abuse The data were cleaned and analyzed using the data analysis program IBM SPSS Statistics (Version 27). Descriptive statistics, including t-tests and chi-square tests, were used to explore nominal and ordinal data group differences when appropriate. Aim 2: Semi-structured interviews or focus groups. Focus group participants had roles in administration, initial intake, medical care, and hospice care. The focus group took place virtually using Microsoft Teams and was recorded for transcription. The semi-structured focus group guide is shown in Appendix A. The focus group lasted for one hour, and each participant was given the opportunity to answer any of the nine questions. 14 One referring hospital case management specialist was interviewed to gain a perspective about discharging patients to the street or temporary housing prior to admission to TIB and the challenges they may endure in the process to understand the discharge process. The hospital employee was recommended by TIB’s administration for the interview. The hospital employee was asked the nine questions shown in the interview guide in Appendix B. The interview took place virtually on Microsoft Teams and lasted 30 minutes. Data Analysis Focus group and interview sessions were rewatched to check the accuracy of the transcription, and edits were made where needed. Once the transcription was cleaned and accurate, it was copied into a Microsoft Excel spreadsheet for analysis. Qualitative descriptive data analysis was utilized to develop codes based on the questions and responses of the interviewees (Doyle et al., 2020). Participant responses were organized by the questions asked during the focus group and interview. The main topics were highlighted within the transcription and condensed into codes. The initial codes were reviewed with the Committee Chair and used to establish patterns of the collected data (Doyle et al., 2020). These patterns and themes assisted in identifying characteristics of residents who were more likely to experience an unplanned hospital visit if they were discharged to the streets/temporary housing before admission to TIB. Aim 3: Development of Infographic 15 The findings from this project were used to draft an infographic for TIB staff to utilize in admissions presentations to hospitals. It highlighted the main characteristics found that could increase the risk of an unplanned hospitalization visit after being discharged from the hospital to the streets or temporary housing before admission to TIB. It will help TIB make the plea for hospitals to keep the patient another night(s) until TIB has a bed available. Results The purpose of this project was to establish characteristics of unsheltered older adults who experienced unplanned hospital readmissions after being discharged from the hospital to the street or temporary housing before admission to TIB’s medical respite care. This was done by gathering 2022 to 2023 fiscal year data on residents who were discharged from the hospital to the street before admission to TIB and comparing those who were rehospitalized within three weeks to those who were not rehospitalized. Additionally, a virtual focus group with TIB administration and an interview with a case management specialist from a referring hospital was conducted to understand the hospital’s perspective on discharging patients experiencing homelessness. The reported findings are below. Aim 1: Resident Intake Data Seventy-two individuals were discharged from the hospital to the street or temporary housing before they could get admission to TIB. Amongst these residents, 11 residents experienced 14 readmissions to the hospital within three weeks of admission. The average time to first readmission was 9.64 ± 5.35 days (range 1-21). Predisposing Factors 16 Andersen Behavioral Model Predisposing Factors are shown in Table 2 and included age, race, ethnicity, gender, sexual orientation, marital status, religion, and victim of domestic violence. Residents who were readmitted to the hospital tended to be younger than those not readmitted (49.6 years compared to 56 years). One woman (5.9% of female residents) was readmitted to the hospital compared to ten men (18.2% of male residents). There were no obvious differences in percent readmission for Hispanic versus non-Hispanic residents. Black residents had the highest percentage (25%) of readmissions. Five of 12 (41.7%) residents who reported domestic violence in the past were readmitted to the hospital compared to none of the three residents who reported no past domestic violence. Table 2 Predisposing Factors Readmitted n=11 Not Readmitted n=61 Total n=72 Average Age (In Years) 49.6±10.8 56.4±11.7 55.4±11.8 Gender (Percent Male) 10 (90.9%) 45 (73.8%) 55 (67.9%) 1 (7.1%) 3 (4.9%) 4 (5.6%) 0 3 (4.9%) 3 (4.2%) 10 (90.9%) 53 (86.9%) 63 (87.5%) 0 2 (3.3%) 2 (2.8%) Hispanic 1 (9.1%) 6 (9.8%) 7 (8.6%) Not Hispanic 10 (92.9%) 55 (90.2%) 65 (80.2%) 0 2 (6.5%) 2 (4.1%) Race Black American Indian Caucasian Native Hawaiian or Pacific Islander Ethnicity LGBT Religion 17 Baptist 1 (11.1%) 0 1 (2.3%) Catholic 0 4 (15.4%) 4 (9.1%) Christian 0 5 (19.2%) 5 (11.4%) Episcopalian 0 1 (3.8%) 1 (2.3%) LDS 1 (11.1%) 3 (11.5%) 4 (9.1%) Non-Denominational 3 (33.3%) 2 (7.7%) 5 (11.4%) Odinism 0 1 (3.8%) 1 (2.3%) Spiritual 2 (22.2%) 4 (15.4%) 6 (13.7%) WES 0 1 (3.8%) 1 (2.3%) None 2 (22.2%) 5 (19.2%) 7 (16.0%) Divorced 0 7 (23.3%) 7 (14.6%) Married 0 1 (3.3%) 1 (2.1%) No 1 (9.1%) 7 (23.3%) 8 (16.7%) Refused 1 (9.1%) 1 (3.3%) 2 (4.2%) Separated 3 (33.3%) 1 (3.3%) 4 (10.3%) Single 4 (44.4%) 10 (33.3%) 14 (29.2%) Widowed 0 3 (10.0%) 3 (6.3%) Victim of Domestic Violence (DV) 5 (50.0%) 7 (24.1%) 12 (25.0%) Currently Fleeing DV 1 (20.0%) 3 (37.5%) 4 (18.2%) 4 (80.0%) 4 (40.0%) 8 (33.3%) 0 1 (10.0%) 1 (4.2%) 1 (20.0%) 1 (10.0%) 2 (8.4%) Marital Status Time Since DV 1 year or more Greater than 6 months Last 3 months 18 Less than 6 months to 1 year 0 1 (10.0%) 1 (4.2%) Enabling Factors Enabling Factors are shown in Table 3. All eleven residents who were readmitted to the hospital were on Medicaid insurance. There were no observable differences between housing categories. Of the 31 residents who were not stable per HMIS guidelines, five (16.1%) were readmitted compared to three of the 17 residents who were stable, 3 (17.6%). Over 80% (9 of 11) of readmissions occurred in quarters three (January through March) and four (April through June), with over 50% (6 of 11) occurring in quarter four. Table 3 Enabling Factors Readmitted (n=11) Not Readmitted (n=61) Total (n=72) Medicaid 11 (100.0%) 49 (81.7) 60 (83.3%) Medicare 0 4 (6.7%) 4 (5.6%) Private 0 5 (8.3%) 5 (6.9%) None 0 2 (3.3%) 2 (2.8%) 1 (9.1%) 3 (4.9%) 4 (4.9%) Average Income on Entrance (In dollars) 233.82±402.00 458.67±539.28 346.25±470.64 Average Annual Income (In dollars) 2805.82±4824.02 5504.04±6471.35 4154.93±5647.69 11 (100.0%) 59 (96.7%) 69 (97.2%) 0 2 (3.3%) 2 (2.7%) Insurance Veteran Percent AMI Extremely Low (30%) Very Low (50%) 19 Entry Benefits from Any Source 4 (44.4%) 24 (41.4%) 28 (36.8%) Stable Per HMIS 3 (37.5%) 14 (35.0%) 17 (29.8%) Chronic Homeless 3 (30.0%) 30 (49.2%) 33 (41.3%) Homeless Situation 10 (90.9%) 53 (86.9%) 63 (77.8%) Temporary Housing Situation 1 (9.1%) 8 (13.1%) 9 (11.1%) Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHYfunded Host Home shelter 6 (54.5%) 33 (55.0%) 39 (48.8%) Hotel or motel paid for without emergency shelter voucher 0 5 (8.3%) 5 (6.3%) 3 (27.3%) 11 (18.3%) 14 (17.5%) 0 1 (1.7%) 1 (1.3%) Staying or living in a family member’s room, apartment, or house 1 (9.1%) 3 (5.0%) 4 (5.0%) Staying or living in a friend’s room, apartment, or house 1 (9.1%) 7 (11.7%) 8 (10.0%) 6.14 10.26 8.20 2.5 ± 1.4 2.9±1.3 2.7±1.35 Housing Status Housing Category Place not meant for habitation Safe Haven Average Months Homeless Average Number of Times Homeless in Last 3 Years Number of Times Homeless in Last 3 Years 20 One 4 (36.4%) 10 (23.8%) 14 (26.4%) Two 2 (18.2%) 5 (11.9%) 7 (13.2%) Three 2 (18.2%) 6 (14.3%) 8 (15.1%) Four or more 3 (27.3%) 21 (50.0%) 24 (45.3%) 90 days or more, but less than 1 year 1 (10.0%) 8 (13.6%) 9 (11.5%) One month or more, but less than 90 days 3 (30.0%) 14 (23.7%) 17 (21.8%) 0 3 (5.1%) 3 (3.8%) One week or more, but less than one month 5 (50.0%) 11 (18.6%) 16 (20.5%) One year or longer 1 (10.0%) 16 (27.1%) 17 (21.8%) Two to six nights 0 5 (8.5%) 5 (6.4%) Client doesn’t know 0 2 (3.4%) 2 (2.6%) 7 (63.6%) 33 (54.1%) 40 (49.4%) Q1 1 (9.1%) 30 (49.2%) 31 (38.3%) Q2 1 (9.1%) 12 (19.7%) 13 (16.0%) Q3 3 (27.3%) 12 (19.7%) 15 (18.5%) Q4 6 (54.5%) 7 (11.5%) 13 (16.0%) Length of Stay in Prior Living Situation One night or less Residing City (Percent SLC) TIB Admit Quarter Need Factors Need Factors are shown in Table 4. One-third of residents on hospice were rehospitalized. Over one-third (34.8%) of people with chronic conditions were readmitted compared to 14.3% of people without chronic conditions. The top three medical reasons for admission to TIB that resulted in readmission were amputation stabilization (33.3%), failure to 21 thrive (33.3%), heart failure (23.1%), and cancer treatment (14.3%). Over twice as many residents not in a wheelchair (18.4%) were readmitted (18.4% vs. 9.1%). Only 14.3% of people with alcoholism were readmitted compared to 33.3% of people without alcoholism. Table 4 Need Factors Readmitted (n=11) Not Readmitted (n=61) Total (n=72) Medical Respite 8 (72.7%) 46 (76.7%) 56 (75.7%) End of Life 3 (27.3%) 14 (23.3%) 18 (24.3%) Amputation 1 (9.1%) 2 (3.3%) 3 (4.2%) Cancer 1 (9.1%) 10 (16.4%) 11 (16.0%) Cirrhosis 0 1 (1.6%) 1 (1.4%) COPD 0 4 (6.6%) 4 (5.6%) Failure to Thrive 1 (9.1%) 2 (3.3%) 3 (4.2%) Heart Failure 3 (27.3%) 10 (16.4%) 13 (18.1%) Infection 0 1 (1.6%) 1 (1.4%) Osteoarthritis Stabilize 0 1 (1.6%) 1 (1.4%) Recuperative 1 (9.1%) 2 (3.3%) 3 (4.2%) Stabilize 1 (9.1%) 0 1 (1.4%) Surgery 0 18 (29.5%) 18 (25.0%) Uncontrolled Diabetes 0 1 (1.6%) 1 (1.4%) Uncontrolled Pain 1 (9.1%) 0 1 (1.4%) Wound Care 2 (18.2%) 9 (14.7%) 11 (15.3%) 8 (80.0%) 15 (55.6%) 23 (50.0%) TIB Program Medical Category Chronic Condition 22 Disabling Condition 11 (100.0%) 60 (98.4%) 71 (98.6%) Mental Illness 5 (50.0%) 14 (53.8%) 19 (42.2%) Alcohol Abuse 1 (10.0%) 6 (25.0%) 7 (16.3%) Drug Abuse 4 (44.4%) 10 (38.5%) 14 (31.8%) Developmental Disability 6 (46.2%) 7 (30.4%) 13 (36.1%) Physical Disability 9 (90.0%) 25 (89.3%) 34 (72.3%) HIV 0 1 (3.8%) 1 (2.2%) Cancer 3 (30.0%) 11 (34.4%) 14 (27.5%) Wheelchair 5 (45.5%) 20 (32.8%) 25 (30.9%) Aim 2: Focus Group and Interview A one-hour focus group with five TIB staff was conducted virtually and included administration, community engagement, resident intake, nursing and hospice staff. A separate virtual interview was conducted with a Case Manager from a hospital who utilizes TIB as a possible discharge placement for individuals experiencing homelessness who require follow-up care. The focus group and interview were organized to gain different perspectives of the systematic approach of hospital discharge to medical respite for those experiencing homelessness using semi-structured interview guides with question prompts that were aligned between the focus group and interview (Appendix A & B). All of the focus group and interview participants were familiar with unplanned hospital readmissions from patients who were discharged from the hospital to the street or temporary housing before admission to TIB and the responses. Three themes emerged from the qualitative descriptive analysis of the focus group and interview data. Medical factors associated with readmission 23 Both focus group and interview participants identified medical factors as one factor associated with readmission. Medical factors included physical and behavioral health conditions, as well as treatments such as medications and wound care. Noncompliance with medications. There was a particular focus on noncompliance with medications, which can lead to unplanned hospital readmissions. TIB focus group participants felt that providing correct medications for each patient and connecting them with a primary care physician before discharge from the hospital would help avoid the risks of unplanned hospital readmissions. Within their licensing policies, TIB was required to send residents to the ER if they missed a medication at the scheduled time, even if it was something like melatonin or vitamin C. Participant T1 said, "Medications play a big part in it, and also the person's overall health." Participant T3 mentioned that "a lot of Med changes we might be missing, and that can be extremely detrimental to their quality of care." TIB focus group participants recalled experiences where residents were not taking their medications from the street before admission to TIB or were not able to have their prescriptions filled. Participant T4 said that pharmacies "….will not prescribe to a homeless individual,” although TIB "patients deserve medications just like any other person." This gap in care created a barrier to the care that TIB provided as TIB needed to "pick up that coordination of care in the middle of whatever crisis they are doing." TIB advocated for residents in these situations as they were likely struggling with their physical health. In addition to physical struggles, TIB participants observed spiritual struggles among those who were admitted to TIB, with a particular focus on hospice patients. Relapse in condition. TIB staff reported that individuals discharged from the hospital to the street or temporary housing typically require follow-up care with medications, bandages, and 24 other care concerns. Being discharged to the street or temporary housing before admission to TIB creates a “break in continuum of care” [Participant T3]. This break in care can lead to significant changes in the individual’s overall health, such as new or worsening of a condition or infection, that require new assessments from TIB nurses. Participant T2 said, “The amount of work medically that has to go into somebody actually being able to stabilize again is quite big." The case manager perceived that sometimes, patients were discharged to the street in stable condition, “but then they get a new infection or their injury becomes worse, and that could have been because they were discharged to the street, but they really did not meet criteria for any other kind of discharge.” Personal factors associated with readmission The focus group and interview participants identified personal factors associated with readmission. Personal factors included lifestyle and behaviors, as well as resident feelings and reactions to healthcare utilization. Lifestyle and Behaviors. The case manager felt that patient behaviors, a factor that the hospital could not fix or control, prevented some patients from being discharged to an institutional setting. They stated, “The best thing we can do is try to encourage them, even though they don't like to go to the shelter because that is where the case managers are that can work with them on housing.” The case manager shared that sometimes, individuals could be denied admission to the TIB if they had behaviors, mental health issues, or noncompliance with medications that would deem them not a fit for the program. However, if their behaviors stabilized, TIB could accept them and treat them at the facility. 25 Feelings and reactions to healthcare utilization. Focus group participants perceived that those who were not directly admitted to TIB had a higher hospital recidivism rate than those who were, which breaks the resident’s trust in TIB staff because the resident could not be taken care of. Participant T2 in the focus group discussed how residents often feel disoriented when they are admitted to TIB from the street or temporary housing as there was "a disconnect in the information that's given to them.” The focus group participants reported that individuals admitted to TIB for hospice care commonly endure spiritual struggles. Participant T5 said, “it's really traumatic news for people to even hear that they're referred to hospice.” This was noted to especially be the case for individuals with chronic illnesses or a history of multiple hospitalizations. T5 mentioned that it can be difficult for patients transitioning into hospice care to understand how to utilize a new form of healthcare. Being referred to end-of-life can create “a crisis kind of situation” [Participant T5]. Resource factors associated with readmission The focus group and interview participants identified resource factors associated with readmission. Resource factors included access to healthcare and resources, insurance, and support systems. Access to healthcare and resources. Focus group participants were asked to identify the biggest challenges to immediately admitting new residents after discharge from the hospital. Bed availability was one challenge, as participant T4 stated, "our bed availability and how many open spots we have because it can get busy very fast." Another challenge was that community partners and providers did not understand TIB’s referral process or how to complete TIB admission packets. the hospital had to be “good stewards of their beds.” If the patient was medically stable, 26 then "this person doesn't need to be in the hospital anymore as long as he takes his medication." They justified discharge to the street or temporary housing in terms of equality, "We can't treat that unhoused person differently just because they don't have a place to live." The hospital case manager talked about how the hospital will contact TIB first to see if the patient would be a fit at TIB. If they are a fit, TIB often has a waitlist for admission to a specific bed type. For example, “patients are expected to be independent in their ADLS” so “they can't go to the independent living side (of TIB) because it's not appropriate based on what their needs are or their complications or behavior.” Lack of access to primary care contributed to the medical status of individuals discharged from the hospital to the street or temporary housing. Focus group participants mentioned that, “About 40% of the people referred to us do not have primary care physicians.” When TIB residents were discharged from the hospital to the street before TIB admission, there was a break in their continuum of care that could result in worsened health status, which required further assessment by TIB staff. Individuals discharged to the street or temporary housing often do not understand how to access medications. When admitted to TIB, staff have to assess their health status further and if it had changed since their hospital discharge. The respondents of the focus group questioned the ethics of creating a gap in care and resources by discharging residents to the streets because the health of the individuals tended to deteriorate in the shelters. The focus group perceived these residents being fearful of shelters. One individual mentioned that some residents have experienced physical and sexual abuse within shelters causing them to feel physically unsafe and to have low self-esteem. The hospital case manager mentioned that hospital readmissions were always possible, and that “Hindsight is 2020” in recognizing whether something could have been done differently 27 to prevent unplanned readmissions. The hospital provided community resources for patients to access after discharge, “And then it is always up to them [patients].” They believed there was always the possibility for things to be done differently, but they were not sure these things would prevent readmission. However, they stated that the future holds “room for improvement.” The case manager perceived those patients with severe mental health issues, noncompliance, or substance abuse were sometimes not a good fit for admission to any type of institutional care because they did not have medical care needs. “We do not even put them in the hospital if we can avoid it because they do not have a medical need.” Sometimes, “they just need to be in a different environment.” Insurance. The case manager had been involved with unplanned readmission to the hospital as well, stating, "Sometimes we cannot do anything differently." Not all patients had Medicaid, and they did not qualify for Medicaid under charity. In these situations, the decision to readmit a resident was “based on what the patient can manage or what they are capable of or what their resources are.” Readmission was also dependent on whether they qualified for the care provided by TIB. Lack of support. In the interview, the case manager also perceived that the risk of unplanned hospitalizations was greater for residents who were discharged to the street because of the limited options they had for resources. “A placement of the facility might be better if that person would be kind of behaved there, but if they do not meet 10A criteria for Medicaid, then Medicaid is not going to pay for that.” 10A Medicaid criteria is the Preadmission/Continued Stay Inpatient Care Transmittal form. This form is filled out to gain approval for a specific level of care in an institutional setting. 28 The case manager also mentioned that often patients who were unsheltered did not have family support or someone to help look after them. “They often have nobody.” With a lack of support, the hospital provided resources to help develop a community support system. “There are so many variables” as to why someone was unhoused. We would probably just discharge them back to wherever they wanted to go, and then sometimes they will come back and change their mind or will stabilize them on medication because they agree to it.” Need for education The results of this project supported the need for educating hospital staff about the importance of direct admission to TIB from the hospital for persons experiencing homelessness. TIB participants stated that they were "educating the masses that we work with and the providers that we work with" to “break barriers and stigmas” so that they could better support residents. TIB administration was educating hospitals and community partners on how to assist patients in obtaining other medical services to help manage their diagnosis to decrease the risk of rehospitalization. TIB participants perceived that hospital staff turnover rates resulted in TIB needing to re-educate hospital employees about the risks of hospitalization about every six months to encourage staff not to discharge patients to the street or temporary housing before admission to TIB. Additionally, TIB also educated residents on when to utilize the ER, urgent care, and primary care to promote investment in their own care needs. Aim 3: Development of an Infographic The findings of this project were utilized to draft an infographic for TIB staff to educate referring hospitals on the impacts of discharging a patient to the street or temporary housing before admission to TIB. The infographic is shown in Appendix C. Discussion 29 The goal of this project was to better understand characteristics of individuals who experience unplanned hospitalization visits after being discharged from the street or temporary housing before they could get admission to TIB. The Andersen Behavioral Model was used as a framework for this project, and predisposing, enabling and need factors were identified as potential contributors to hospital readmission of TIB residents who were admitted from the street or temporary housing after a hospitalization. In this project, several predisposing factors are associated with increased risk of rehospitalization. Surprisingly, increasing age was not associated with hospital readmission. Rather, the average age of the residents who were readmitted was 48.6 years, compared to 56.4 years for those not readmitted. This may be because persons experiencing homelessness commonly experience pre-mortality due to disabling conditions and lack of healthcare while residing on the street or in temporary housing which can make them functionally older at a younger age (Zordan et al., 2023). Half of individuals who were readmitted to the hospital within three weeks of admission to TIB reported a past history of domestic violence compared to 25% of those not readmitted. Per previous literature, domestic violence is a significant contributing factor for persons experiencing homelessness (Zhao, 2022). Domestic violence has also been found to worsen symptoms of physical health, chronic conditions, and mental health (Stubbs & Szoeke, 2021). TIB staff focus group participants identified other personal characteristics that impact how residents respond to being admitted to TIB which might increase the risk of rehospitalization. Residents often feel disoriented and struggle to adjust or adapt to TIB after going from the hospital to the street and then back to a care facility. They often struggle to understand their new environment with different regulations and care teams. Residents may also 30 be fearful of going back to the street or shelter from the hospital because they are worried about enduring physical or sexual abuse. This causes individuals living on the streets or in shelters to feel physically unsafe, in which they may seek out a hospital to feel safe (Grech & Raeburn, 2021). Experiencing homelessness can lead to further disorientation, memory issues, and cognitive impairment (Rapaport et al., 2023). TIB staff also noted that individuals living on the street have decreased self-esteem, as they desired autonomy and the ability to live independently. This can lead to worsening mental health and further cause the individual to feel disoriented or delayed when they are admitted to TIB from the street or temporary housing. Our findings suggest that limited financial limitations are associated with increased risk of rehospitalization. Most residents had zero income upon admission to TIB. Many of the residents readmitted to the hospital within three weeks were staying in an emergency shelter between hospital discharge and TIB admission. With limited income and residing at an emergency shelter, individuals risk the worsening of, or new onset of, medical conditions because they lack the proper means and support to follow up with healthcare needs. In addition, TIB staff viewed the shelter as a place that residents were fearful of and where their health may deteriorate because they did not have access to follow up care. Enabling factors that might contribute to increased risk of rehospitalization were access to healthcare and other support. Most TIB residents have Medicaid coverage. Medicaid is required to qualify for specific care needs like a nursing home or extended stays in the hospital. However, persons living on the street or temporary housing before admission to TIB may have difficulty accessing care because of their Medicaid status. Individuals experiencing homelessness commonly lack a support system and are estranged from family and friends This lack of a support system may contribute to a resident’s risk of rehospitalization as they may not have other 31 options available to support their needs, making them more likely to be discharged from the hospital to the street or temporary housing before they can be admitted to TIB. Many of the medical needs of TIB residents are directly related to their need for housing. A resident’s medical needs are a key factor contributing to their risk for rehospitalization after being discharged from the hospital to the street or temporary housing before admission to TIB. While the medical record data did not show an observable relationship to rehospitalization of TIB residents, the case manager perceived that mental health and behaviors of the residents impacted both where a patient was discharged from the hospital and why they were readmitted. Patients with wounds need frequent dressing changes with new and clean supplies each time. If individuals cannot maintain their wound dressings, the wounds could get worse, creating an opportunity for infection that when recognized at TIB may require hospital readmission. This issue can be addressed by hospitals keeping patients until they can be admitted to TIB. It is not surprising to find that individuals with chronic health conditions and cancer were more likely to be readmitted to the hospital. What is surprising was the finding that one third of patients on hospice were rehospitalized. Recent literature suggests that socioeconomic factors as well as race and ethnicity could increase the chance of an individual on hospice to seek the hospital for care. Underrepresented populations were found to be at a higher risk for hospice discharge due to hospitalization visits. (Russell et al., 2019). Additionally, younger adults on hospice may tend to seek out hospitals for treatment due to the fear of the end-of-life diagnosis. 32 A key finding of this project is that individuals who are discharged from the hospital to the street or temporary housing have unmet healthcare needs individuals that may result in increased unplanned hospitalizations within three weeks of admission to TIB. Unmet health care needs can include missing or not maintaining medication schedules, unaddressed wound care needs, and relapsing in substance abuse. Unmet healthcare needs can contribute to the worsening of a condition or new conditions becoming present. See Figure 1 below. Figure 1 The Cycle of Hospital Readmissions After Discharge to the Street or Temporary Housing TIB educates health care providers and hospitals on how to best advocate for individuals experiencing homelessness, what resources are available, and how to connect patients with TIB better if that is an option for them. This education may reduce the risk of rehospitalization if they are better connected with appropriate resources for their needs. There are several limitations in this project. During July 1, 2022 and June 30, 2023, TIB was not required to collect SPDAT scores on all residents, resulting in a limited amount of data to analyze. Because of the small sample size and missing data, we did not include statistical 33 analyses in the results. Hospital records from referring hospitals were not available on patients before their admittance to TIB and the TIB also did not have a consistent method for keeping a record of hospital readmissions for residents. This prevented us from understanding what diagnoses led to hospitalization. Lastly, there was only an opportunity to interview one hospital employee from one referring hospital. Having more perspectives from additional hospitals and employees could have helped in diversifying the qualitative data collected on the systematic level. Finally, the purpose of this project was to identify factors that contribute to the risk of rehospitalization of TIB residents who experienced time on the streets or temporary housing between a hospital discharge and TIB admission. Therefore, the data are not generalizable to individuals who were not admitted to TIB or to individuals admitted to other care settings. Conclusion Discharging a patient from the hospital to the street before admission to TIB can lead to new or worsening of current conditions in which may require readmission to the hospital within three weeks of admission to TIB. Key considerations to identifying a person at risk for rehospitalization are medical needs, personal factors, and available resources. Future research with larger samples and which includes hospital medical record data and resident perspectives are warranted. 34 References Abbs, E., Brown, R., Guzman, D., Kaplan, L., & Kushel, M. (2020). 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The purpose of this project is to identify demographic, social, and health characteristics of unsheltered older adults who experience unplanned hospitalizations after being discharged from the hospital to the street or temporary housing before admission to The Inn Between (TIB). This interview will take approximately 30 – 60 minutes to complete. This interview will be recorded and transcribed for further analysis, but your responses will be kept confidential and you will not be identified by name. Your participation is voluntary, and, while I value your insights about this topic, you can choose not to respond to any of the questions I ask. 1. What is your role at TIB? 2. TIB has experienced unplanned hospitalizations of residents who were discharged from a hospital to the street or temporary housing before being admitted to TIB. Are you familiar with any of the residents who were discharged to the street or temporary housing before being admitted to TIB (Yes/No)? 3. What are characteristics that you think are common for residents who are discharged to the street or temporary housing before being admitted to TIB? (e.g. gender, age, chronic conditions, chronic homelessness, substance abuse disorder, lack of insurance, lack of family or social support, etc.) 4. What do you think are the biggest challenges to immediately admitting new residents after being discharged from the hospital, rather than discharging them to the street or temporary housing? 5. Sometimes, there have been unplanned hospitalizations of these residents soon after admission to TIB. Have you been involved with the issue of unplanned hospitalizations of these residents? (e.g. TIB intake, direct interactions/care of residents, decision to rehospitalization, review of rehospitalization). (Yes/No). 6. If you answered yes, how have you been involved (e.g. what was your role)? 41 7. Do you think the risk of unplanned hospitalizations are greater for residents who were discharged from a hospital to the street/temporary housing, than for residents who were admitted directly from the hospital? (Yes/No) a. Why or why not 8. How could these hospitalization visits have been prevented? a. Please give specific examples. 9. What do you think TIB could do to prevent unplanned hospitalizations in this resident population? Is there anything else you would like to tell me about unplanned hospitalizations at TIB? If I have any other follow-up questions, can I contact you? Thank you for your time. 42 Appendix B Interview Guide for Hospital Employees Introduction: Thank you for taking the time to participate in the Master’s Project for TIB quality improvement. The purpose of this project is to identify demographic, social and health characteristics of unsheltered older adults who experience unplanned hospitalizations after being discharged from the hospital to the street or temporary housing before admission to The Inn Between (TIB). This interview will take approximately 15 – 30 minutes to complete. This interview will be recorded and transcribed for further analysis, but your responses will be kept confidential and you will not be identified by name. Your participation is voluntary and, while I value your insights about this topic, you can choose not to respond to any of the questions I ask. 1. What is your role at the hospital? 2. What is your relationship with TIB? 3. TIB has experienced unplanned hospitalizations of residents who were discharged from a hospital to the street or temporary housing before being admitted to TIB. Are you familiar with any of the patients who were discharged to the street or temporary housing before being admitted to TIB (Yes/No)? 4. What are characteristics that you think are common for patients who are discharged to the street or temporary housing before being admitted to TIB? (e.g. gender, age, chronic conditions, chronic homelessness, substance abuse disorder, lack of insurance, lack of family or social support, etc.) 5. What are the reasons why patients are discharged to the streets or temporary housing? (e.g. insurance, not enough beds, etc.) 6. Sometimes there have been unplanned hospitalizations of these residents soon after admission to TIB. Have you been involved with the issue of unplanned hospitalizations of these residents? (e.g. TIB intake, direct interactions/care of residents, decision to rehospitalization, review of rehospitalization). (Yes/No). (If you answered no, skip to question 11) 7. If you answered yes, how have you been involved (e.g. what was your role)? 43 8. Do you think the risk of unplanned hospitalizations are greater for residents who were discharged from a hospital to the street/temporary housing, than for residents who were admitted directly from the hospital? (Yes/No) a. Why or why not 9. How could these hospitalization visits have been prevented? a. Please give specific examples. Is there anything else you would like to tell me about discharging patients to the streets or temporary housing before admission to TIB? Do you know anyone in a similar position as yours in another hospital that I might be able to reach out to? If I have any other follow-up questions, can I contact you? Thank you for your time. 44 Appendix C Draft of Infographic