When recovering at home after a hospital stay isn’t an option

One of Dr. Sarah Stella’s patients had been homeless for about four years when he was struck by a car, the impact fracturing his pelvis and breaking his femur. 

The 45-year-old man had surgery at Denver Health, spent a few days recovering in the hospital, and then left — to sleep in his tent. 

Stella, an internal medicine doctor at the safety net hospital, recalled how the man described in a post-surgery appointment how much his body and his bones still hurt. “He’s having a lot of pain, a lot of difficulty walking,” she said. “He’s making slow progress with physical therapy, and he now needs a walker. He sleeps on the ground.”

Denver Health cared for at least 6,000 patients who were homeless in 2021, according to the hospital’s best estimate. Even when the hospital knows a patient is homeless, and that discharging them to the streets to recover increases the odds they will reappear at the emergency department, there is often no place else to send them. 

A Colorado Coalition for the Homeless respite program with 20 beds has been receiving from 600 to 900 referrals from Denver Health, other hospitals and shelters each year. About three-fourths of those folks — some with oxygen machines or IV antibiotics or wheelchairs — actually get a bed. Others go back to sleeping outside or in a shelter.  

That gap in care is the focus of a new, 75-bed “recuperative care center” for the homeless scheduled to open to its first patients this fall. The Coalition for the Homeless project just north of downtown Denver will take up three floors in a nine-story building that also includes supportive housing units. 

Beacon Place, a housing complex of the Colorado Coalition for the Homeless, on Aug. 31, 2022, on West Colfax in Denver. Beacon opened in 1999 and has 20 respite beds, not enough to fill the need. (Olivia Sun, The Colorado Sun via Report for America)

Miriah Nunnaley, the coalition’s director of recuperative care, has been scrambling to help as many people as she can. The most common health issues are breathing problems, including people with cardiopulmonary disease trying to live outdoors at a mile-high elevation. Others have wounds that don’t heal because they’re walking on them 6 to 10 miles a day, she said. There are lots of cases of sepsis. 

“Most of our referrals come from the hospitals, shelters and the community,” she said. “I’ve had church members call me and say there is this guy I’m worried about on our street corner who doesn’t have legs and his wheelchair keeps getting stolen.” 

The hardest people to turn away, said Nunnaley, a former hospice nurse, have been those who need a comfortable place to die. In the new center, she hopes to designate a few beds for hospice care. 

“There are no hospice services for the unhoused and they end up dying in the hospital,” she said. “Our country should be ashamed of that.” 

Almost half of the people who stay in the coalition’s respite beds are 55 and older, and current statistics show the average life expectancy for people who are chronically homeless is 54. 

“It’s really backfired”

The coalition patched together a complex financing and ownership structure to build the recuperative care center, relying on bonds, tax credits, city and state funds and investors for the $46.5 million project. 

The new center, on California Street, will have a lobby with an ambulance bay and a kitchen on the first floor, recuperative care beds on the second and third floors, and then 98 apartments on the six floors above. The new space will allow the coalition to care for about 400 people each year who need time to recover from an injury but don’t have a home. On average, each patient will stay from 30 to 45 days, with a goal of helping them find housing or at least get on a waiting list by the time they leave. 

Some of them will move upstairs, into the lofts that are the coalition’s 19th supportive housing project in the past 30 years. 

Along with the new space, the coalition will grow its medical team from about 15 now to about 60, including nurses, behavioral health specialists and psychiatry. The center will have medical staff on site 24 hours per day, and will have a mix of semi-private rooms and shared sleeping quarters. 

“There are a lot of folks who can’t be safely discharged to the streets and there have been stories both in Denver and other communities where hospitals have dropped people off, sometimes in hospital garb, in front of the Samaritan House or St. Francis Center,” said John Parvensky, CEO of the Coalition for the Homeless. “And it’s really backfired.”

What typically happens next is that the shelter can’t keep them, and they return to an emergency department for treatment that ends up costing the hospital and the government even more money, Parvensky said. No one will deliver oxygen to a shelter. And shelters aren’t able to provide daily wound care or maintain IVs. 

“The idea is that this is a step down, an appropriate place to discharge a patient and prevent folks from cycling back into higher-level-cost care,” he said. “And by connecting them to housing, we can reduce the likelihood that they’ll end up back in the hospital.” 

John Parvensky helped start the Colorado Coalition for the Homeless in 1985 and has led the organization for nearly 37 years. (Olivia Sun, The Colorado Sun via Report for America)

National research, from the Center on Budget and Policy Priorities, found that providing a place to sleep and medical care reduces emergency room visits by 33% and days in the hospital by 23%. 

The new center is intended to help those who are frequent users of emergency rooms. For a few years, the coalition has used 20 respite beds set up inside Beacon Place, an apartment building on Colfax Avenue that’s owned by the coalition. 

It hardly fills the need, which was 900 referrals from hospitals and shelters in 2019 and is on pace this year to reach 900 again. The requests dipped in 2020 and 2021 as hospitals were overwhelmed with COVID and not accepting as many other patients, though the coalition, the city of Denver and other organizations provided respite motel rooms to thousands of people who were homeless and had COVID during those two years. 

“Home at last”

One recent patient at the 20-bed respite center was a 70-year-old man with chronic mental health issues, including bipolar disorder, and a long list of medical issues including a bleeding skin condition, heart problems and arthritis that makes it painful to walk.

His story had a rare happy ending, but not without years of heartache for his sister in Florida. 

Vivian, who did not want her full name used because her brother is now showing signs of dementia and couldn’t consent to telling his story, bought her brother a plane ticket from Denver to Florida about two weeks ago. He had been living on the streets and in shelters in Colorado for the past three years, in and out of the hospital, until finally ending up in a bed at the coalition’s respite center. 

Coalition for the Homeless staff connected with Vivian, who asked them to keep her brother safe until she could get him to Florida. In August, a caseworker from the coalition brought her brother to the airport and got him on the plane. And when he arrived in Florida, Vivian surprised him by showing him the house she had bought him, fixed up with a shade umbrella on the patio the color of pool water.

She also had a cake decorated with a house of frosting. “Home at last,” it said in red and blue.

Her brother could never get better, Vivian said, because every time he got care at the hospital, he went back outside, where he was confused and in pain. He was kicked out of shelters because his skin bled. Once, he crawled into the back seat of a parked car to sleep for the night and was arrested for trespassing. He failed to make his court date and ended up in jail, though the charges were later dropped, Vivian said.

“It was pretty much a nightmare the whole time,” said Vivian, who could keep in touch with her older brother only when he had a cellphone. She had gotten him into a mental health clinic years earlier in Florida, but he walked away and hopped a plane to Denver.

Already, after about two weeks living in his new home, he looks “100% better,” Vivian said. She’s set him up with housekeeping services, scheduled mental health and physical therapy, bought him a television and put him on her phone plan. 

Without her, “he’d be dead for sure,” she said. “There is no doubt.” 

She’s grateful for the staff at the Coalition for the Homeless that helped get him back to Florida, and “all the people of Denver” who gave him food and clothes, and even a truck driver who let him ride around with him on deliveries one night when it was freezing, she said. “I sleep much better now.” 

“Patients are invisible”

Even with the new recuperative care center, the coalition expects it will still have to turn away about 10% of people who request beds, in part because some need a higher level of care, usually a skilled nursing facility or nursing home. 

Part of the problem in closing that gap is that health care and housing experts don’t even have an accurate count of how many homeless folks are getting released from hospitals in Colorado. 

Downtown buildings and apartment complexes on Aug. 31, 2022, from California Street in northern Denver. (Olivia Sun, The Colorado Sun via Report for America)

Denver Health is now attempting to collect the data, but until recently had not tracked whether hospitalized patients have a home. Most hospitals aren’t asking about housing status, and computer systems haven’t been set up to flag patients who give a shelter or motel address when they check in, Denver Health’s Dr. Stella said. 

“A lot of patients are just invisible. We don’t know if they are living in a motel or sleeping in their vehicle or living in a tent,” she said. “Some don’t disclose that because of stigmatization, or shame. It’s a missed opportunity for connecting folks.” 

Incomplete data shows that in 2021, Denver Health hospitalized 1,200 people who said they were homeless in its surgery, critical care and adult medicine departments, which would not include psychiatric or obstetrics patients. 

Those who are homeless are often kept in the hospital a few days longer than they would otherwise because there is nowhere to send them, Stella said. Sometimes, the hospital can find them a hotel room through a city of Denver program or a bed at the coalition’s respite center. 

“We really do whatever we can to try to meet the need for that person,” Stella said. Sometimes, she said, “it’s not the appropriate level of care, but there is a huge gap. They can’t go back with their broken leg to their tent or stay in their vehicle.”

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