Patient dumping in America: Hospitals discharging sick homeless back onto the street

Skid Row marks a 40- to 50-block area in downtown Los Angeles where streets are lined with tents and tarps, and living conditions are far from sanitary. Once meant to serve as a destination for homeless resources, over the last decade, the area has become what homeless advocates call a dumping ground where hospitals leave still-sick, destitute patients to fend for themselves.

The LA City Council centralized its homeless services there in the ’70s, prompting the birth of a neighborhood that would later maintain the nation’s most centralized homeless population— by some estimates, nearly 2,000 people.

The problem of homeless patient dumping— or failing to make continued care arrangements when a patient is well enough to leave the hospital but too ill to return to the streets— is only fueling Southern California’s homeless problem, argue advocates familiar with the issue.

Paul Gregerson is the chief medical officer at the John Wesley Community Health Institute in Los Angeles, which operates nine clinics, two of which tend to the homeless. Its clinic in Skid Row sees 8,000 unduplicated patients and manages 25,000 medical visits per year.

Gregerson recalled a schizophrenic patient who arrived at the institute last fall after being discharged from a hospital with only 30 days’ worth of medication. The drugs were essential for quieting the voices in the man’s head that demanded he hurt himself, but as he bounced from the hospital to an urgent care facility and finally a midnight mission, he ran out of his pills. The voices returned, and the man became suicidal.

“We put him on the medications he needed and set him up with the Department of Mental Health— this was six months after he tried to hurt himself,” Gregerson told

Stopping patient dumping

Although alleged reports of homeless patient dumping span from Alabama to Nevada, perhaps no state has gotten more flak for the issue than California. The problem in California can partially be attributed to the state’s limited affordable housing as well as its high concentration of the homeless, Gregerson said.

According to the U.S. Department of Housing and Urban Development (HUD), California’s homeless population accounts for 22 percent, or about 136,830 people, of the nation’s total homeless population. California is one of six states where more than half of the homeless population is living in an unsheltered location— that’s about 91,000 people, according to a 2013 HUD report, the most recent data available.

LA City Attorney Mike Feuer has filed multiple lawsuits against hospitals for alleged homeless patient dumping. He filed his latest in April against a hospital for allegedly dumping a 38-year-old schizophrenic homeless woman, wearing only paper pajamas, on Skid Row. Various reports from the past decade allege similar cases: a hospital van in 2007 dropping off a paraplegic man on Skid Row, leaving him crawling in the street wrapped in a soiled gown and a broken colostomy bag; and another female patient in 2006 transported by taxi cab to the area wearing only a hospital gown and slippers.

“We’ve heard stories of [hospitals] busing people to Skid Row, giving them a one-way ticket or almost putting pressure on them, or discharging them at 2 in the morning— just really kind of mean-spirited ways of, ‘You’re done with us; don’t come back,’” Paul Leon, CEO of the Illumination Foundation, in Irvine, Calif., which runs three respite care centers, told

The Affordable Care Act docks Medicare and Medicaid payment to hospitals that have excessive readmissions of patients within a 30-day window. But Leon pointed out that often, when homeless people aren’t insured and don’t have family, cases of patient dumping go unnoticed in the first place.

According to a 2014 National Coalition for the Homeless survey of 142 multiethnic homeless people, nearly half reported feeling discriminated against by a medical professional.

A two-way struggle

Caring for an uninsured homeless patient in the emergency room costs an average of $2,000 a day, but admitting a homeless patient to the hospital can pose challenges that extend beyond a financial burden.

Because homeless patients often have multiple chronic diagnoses, including trauma and mental health illnesses, hospitals typically have two choices when admitting them: caring for them about twice as long as typical patients or— if community resources are lacking— discharging them inappropriately, said John Lozier, executive director of the National Health Care for the Homeless Council.

“It’s a rock in a hard place for hospitals, and we certainly understand the difficulties they face with that,” Lozier told “[Homeless people] can’t do what other people do, which is recuperate at home.”

A common factor in most alleged homeless patient dumping stories is likely noncompliance, said Jennifer Bayer, vice president of external affairs for the Hospital Association of Southern California, which represents private and public for-profit hospitals. She noted that federal law prohibits hospitals from detaining patients or transporting them anywhere, even medical respite care centers, against their will.

“That’s one of the biggest challenges that the public misses— that hospitals aren’t prisons, and the law follows the right to the patient. And the patient has the right to refuse medication, to refuse housing, and go where they want regardless,” she said.

Bayer’s organization partners with Homeless Health Care Los Angeles to run training programs in local hospitals to help educate discharge planners and social workers about available community services. But she added that, due to the challenging nature of discharge planning, as well as the lower average salary compared to other health care jobs, the position typically has a high turnover rate in hospitals.

“It’s really frustrating for us because we get the bad rap on this, but our hands are very much tied, too,” Bayer said.

Even when the proper resources and staff are on hand, admitting the homeless to the emergency room comes with problems as simple as getting a patient’s real name. “In most cases, they don’t give their real name, and have no address or make stuff up,” Bayer said.

Daniel Castillo, CEO of LAC+USC Medical Center, the largest health care provider in LA County, said that how hospitals and downstream providers like medical respite care centers are reimbursed can play a role in the issue of homeless patient dumping.

According to the National Health Care for the Homeless Council, medical respite programs use a patchwork of local grants and other one-time-only funding to run their residential and health services, while health centers that are federally qualified are able to bill Medicaid and Medicare for reimbursement.

Bridging the gap

Lozier’s organization, which provides training and resources to health workers who care for the homeless, has developed 70 medical respite care facilities and counting across the United States.

The California Health and Safety Code requires hospitals to have a discharge policy in place, and recommends hospitals send recovering homeless patients to a medical respite center like the one Lozier’s organization runs. Those centers can be a freestanding facility, a homeless shelter, a nursing home or transitional housing.

Determining the appropriate place to send homeless patients and having a system in place are the two main keys to preventing homeless patient dumping, homeless advocates say.

“There are more homeless in LA … but there hasn’t been a community-wide collaborative effort between hospitals and other key players to develop protocols and establish them— implementing how patients can be discharged, under what conditions and to where,” Gregerson said.

Equally important, Gregerson said, is ensuring the patient is signed up for Medicaid and has a primary care provider. In 2014, the Affordable Care Act expanded Medicaid coverage to those under 65 years old who have incomes up to 133 percent of the federal poverty level.

“The biggest problem is even though the Affordable Care Act has made health care available not based on socioeconomic status, that doesn’t mean everyone’s accessing it,” Gregerson said. “So this is a prime opportunity to get people to access the system because then every single patient that’s discharged will go back to their primary care provider on a follow-up basis, long term.”

Taking that step can help hospitals avoid exorbitant costs, said Leon, of the Illumination Foundation.

“If you’re a hospital and you discharge a homeless patient to the street, and they never make their first follow-up with a physician, they’re 92 percent more likely to show back up at the hospital for the same thing,” Leon said.

Orange County had previously hired Castillo, of the LAC+USC Medical Center, as an administrative manager in 2006 to run the area’s Health Care Agency’s Medical Services Initiative (MSI). MSI was funded with federal and county dollars and helped create an electronic health care system called Safety Net Connect. Hospitals and physicians can use the web-based program to help monitor homeless patients’ health as well as the health of patients who are sheltered but uninsured. In 2007, 12,000 patients were enrolled, and by 2011, 65,000 were enrolled, Castillo said.

Using electronic medical records can help streamline discharge procedures when hospitals admit homeless patients, Castillo pointed out.

A lack of funding

Hospitals and homeless advocates agree that carrying out discharge policies and executing patient tracking depends first on the employment of a discharge planner, as well as a designated team of social workers who specialize in trauma and mental health counseling.

Lozier, with the National Health Care for the Homeless Council, noted that because many homeless patients have multiple diagnoses, as well as poor health literacy, “It’s hard for hospitals to muster the resources to address those issues comprehensively.”

“Hospitals need to be able to make discharge plans that clients understand, “he said. “That does come down to a one-on-one situation with social workers and discharge planners understanding both the capabilities involved and the community resources, which end up being the problem. The first part of that is doable, but the community resources are simply lacking.”

He said the growing movement to develop medical care respite centers since the 1980s, when homelessness exploded in the U.S., has the potential to prevent homeless patient dumping, but ultimately that the issues in California are rooted in a lack of funding across the board.

“The problem for hospitals is they’re not in a position to guarantee housing— that’s not their job. It’s not really anyone’s ultimate responsibility,” he said. “The responsibility really lies with the broader economic and political housing, and making sure people have adequate income.”