Hospitals find ways to navigate homeless into shelters

Oct. 25--WOODLAND HILLS -- Almost once a week, Guadalupe Tolentino's liver and bloodstream drown in liquor and sorrow, and that gets him a free ambulance ride to Kaiser Permanente's Emergency Department.

There, doctors and nurses flush the alcohol out of the 55-year-old man's veins with IV fluids, calm his tremors with vitamins and medications and, if he stays long enough, provide him a meal and clean clothes.

Despite an existence in crisis, liquor is never far from Tolentino's mind, and neither is Kaiser's emergency department in Woodland Hills, which he visits up to 40 times a year.

For Tolentino and other chronic homeless men and women like him, the emergency department is a place of stability and peace, where the sound of rushing crash carts and the beeps of telemetry monitors can be a lullaby compared to the sounds of sleeping on the streets.

But for the hospital's "homeless navigator" Jonathan Lopez, those such as Tolentino, known as frequent flyers, also are never far from his mind. Most pose no harm, but those repeated returns show that their chronic drug or alcohol dependence as well as their homelessness go untreated. And it means the hospital pays an average of $1,500 a night for their stay, money that is never recuperated.

"When a frequent flyer returns to our ED my adrenalin gets going," said Lopez, "I instantly start to process where I might be able to coordinate a placement," Lopez said. "I get to relate to these individuals in an extraordinary way."

Hospitals around the country have been increasingly using homeless navigators to help place indigent men and women into treatments centers or housing after discharge. In the Kaiser system, which has 14 medical centers in Southern California, Lopez's position is part of a first-of-its-kind, two-year-old pilot program launched at the Woodland Hills campus. He said he crafted the program after watching a similar approach formed by the San Gabriel Valley Consortium on Homelessness.

Lopez works to help 40 to 50 homeless patients a month who come to the ED looking for care. He and a team of nurses, caseworkers and others try to place the men and women in treatment centers to help with their addictions, or locate transitional housing, sober living environments or other programs.

It's a difficult vocation. A knot of obstacles, including stretched resources, lack of beds and housing, and a resistance by the patients to treat their alcohol and drug dependence or leave the streets for good, make Lopez's work seem futile.

Still, he tries.

In the last 18 months, Lopez and his team have worked to place 500 men and women into emergency shelters, transitional housing, detox and residential addiction rehabilitation programs.

"My greatest challenge is having immediate availability of homeless resources so that we can end homelessness at the time of discharge from the Emergency Department," Lopez said.

In the last few years, more hospitals have hired navigators to make sure the homeless have somewhere to go after they are discharged, health officials said. The most successful programs are those that can lead the homeless to supportive housing, where their addictions and mental illnesses can be addressed in a safe environment.

But patient dumping -- in which hospitals transport homeless men and women back to Skid Row -- continues to cast a shadow over the way medical facilities work with poor patients.

In 2006, the Los Angeles City Attorney's office filed criminal charges against Kaiser after a 63-year-old patient from the system's Bellflower hospital was found wandering Skid Row in a hospital gown and slippers. Kaiser agreed to fines and a program that trains staff on how to work with the homeless when they are ready for discharge.

Similar cases involving other hospitals followed. In 2008, Hollywood Presbyterian Medical Center also agreed to settle allegations with the City Attorney's Office after it left a paraplegic man crawling around downtown Los Angeles' Skid Row in a hospital gown and with a colostomy bag.

No lawsuits are currently pending but investigations are underway, said Frank Mateljan, spokesman for the City Attorney's Office.

"Our office is currently working with our service provider and law enforcement partners to investigate several reported incidents of patient dumping on Skid Row after seeing an increase over the past year," Mateljan said.

Discharging the homeless is a complicated issue, agreed Jennifer Bayer, spokeswoman for the Hospital Association of Southern California.

In Los Angeles County, where services are spread out and where there are 6,000 emergency beds in shelters for nearly 60,000 homeless, hospital staff say they struggle to find a place that will take these patients upon discharge. The result has been accusations of patient dumping.

"It's a frustrating issue because hospitals are caught between a rock and hard place," Bayer said. Some homeless patients won't give their name. Others give consent to be transported to the Union Mission, then change their minds while being transported. A few who know the system also take advantage of emergency departments, which by law cannot turn anyone away, Bayer said.

"So much of this comes down to patient rights," Bayer said. "You've got a very difficult population. We can't force them into treatment. We can't force them into recuperative care."

Physicians and staff in emergency care say they too have felt the frustration of treating a patient, only to see them again, or else not know where they might go after they are discharged.

"I think emotionally you hope to make a change in people's lives," said Dr. Ara Gabrielian, an emergency physician. "Before the program started, there was a feeling of hopelessness."

But the navigator program is another prevention tool, to help untie the knots, Gabrielian and others said.

Nationwide, hospitals provided more than $41 billion in uncompensated care in 2011, the last year for which data is available, although not all of that was spent on the homeless patients, according to the American Hospital Association.

Costs aside, Lopez said he also works with the homeless in the community who are referred to him from churches, service agencies, and even other homeless who he has met in the emergency department.

"When I accepted this job I told myself to be successful I would need to be as open as possible and completely non-judgmental," he said.

And patient.

On a recent afternoon, Lopez met with Tolentino to tell the homeless man that the Tarzana Treatment Center had a spot for him.

Tolentino, who sleeps behind a local Home Depot, works as a day laborer but drinks so much that he's fallen off of ladders while on the job. He has gotten cuts on his face from street fights, or else passes out on the concrete behind the Home Depot where he sleeps.

"When I was 12, I used to see older men sit and drink and they told stories and laughed and seemed so happy," Tolentino said.

He agreed to try sobriety, but a few days later, he was back on the streets, Lopez said.

"It can take from 1 to 10 attempts," Lopez said. "So I usually think 'OK this is only the sixth time' -- as an example. So I realize that being a homeless navigator is a process and I never give up, ever."

Lopez said when he was a young child and for most of his life -- he dreamed of saving people.

"I never get discouraged," Lopez said. "We can't always cure homelessness, but we can disrupt the pattern of chronic homelessness which can lead to helping to change the individual's life."

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