Recidivism

 

You might wonder why “recidivism” in the subject line. In the context of readmissions, the word comes up often—and in particular, those who cycle from shelters to the street to the ER. Rinse. Repeat.  I focus on the Northeast, but my guess is your regional experience is like mine.

You have noticed over the last two to three years, big cities, and NYC in particular, have seen a marked uptick in the number of people sleeping on the sidewalks. The causes of the increase stem from budget cuts, the economy and myriad other factors you can probably surmise.

However, the purpose of my post is not to delve into the how’s and why’s of the crisis but to highlight a blind spot most of us have regarding the reason someone would prefer a forty degree slab of sidewalk versus a seventy-degree cot in a shelter.

Admit it, most of us, including me, form snap judgements at times and label individuals “a bit off” when they opt for a less conventional approach to life. For our purposes, that means exposure to the elements, getting hassled by thugs or the police—and most relevant, undoing the choice care these folks receive during their inpatient stay. Well, we need to revise our views.

We all face the difficult discharge of the homeless person who needs to refrigerate meds, use a syringe, store expensive pills, or return for follow-up ASAP. Why in the heck would they put their health in jeopardy? How about this for a reason:

“The shelter system appears to have descended into a hellish combination of “One Flew Over the Cuckoo’s Nest” and “Lord of the Flies,” where residents must fend for themselves and fights break out — sometimes over absolutely nothing.

For many, the system is a de-humanizing gauntlet where privacy is a rare commodity and residents often struggle to maintain their dignity. Some shelter residents live in a constant state of fear. Routinely residents are cut with razors, whacked with padlocks wrapped in socks, beaten bloody over minor disputes.

Domestic violence is everywhere and shelter staff are regularly attacked.

“I have to sleep with one eye open, one eye closed,” said Raymond Torres, 33, sporting a scar on his lip from getting punched at a shelter so hard his teeth came through his face.

Torres, interviewed by The News on Monday, stays at the Jack Ryan Residence Homeless Shelter on W. 125th St. in Harlem.

“I have to sleep with my sneakers on,” he said. “I have to be careful not to bring anything of value because they’re going to break the locker and take everything.”

Sounds wonderful, doesn’t it? How tone deaf do the social workers or we sound when we bombard these patients with a fusillade of disapproving retorts, eye rolls, or subtle gestures after offering them the apparent “standard of care” when they are ready to go. I mean, why in the hell would they move to the street? We got plenty of shelter beds to send them to. Silly people we must be.

I think most of you know in your hearts the shelter system is miserable. But I highlight the above because it’s probably worse than you think; and in considering discharge plans, any d/c preparation will require you to force a mental reshuffle. I certainly don’t have a golden ticket to get these patients to the right place. However, what I do possess is some sage advice. Do offer follow-ups at your clinics during every encounter. Avoid meds that require injection or refrigeration. Nod understandingly when a patient defers shelter placement for the reasons stated above. And ask patients what it’s like on the street (you should)—and discover what they have to go through to live without a roof over their heads and how they eat and survive. It will make you a better doc and perhaps help you form a more idealized discharge plan so as to help the patient avoid a needless ER return trip or admission.

I know it’s not the perfect solution. What these patients need is housing, reliable mental health and substance abuse services, and job training. Nevertheless, it’s the best we can do. Just being aware and showing these patients “you get it” will allow you to connect with them on a deeper level. That in itself is a stride forward and an opportunity to add value to someone’s care and make their life, perhaps, a tad more whole.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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