Background: Discharge planning is an important component of safe and efficient hospital care. While standardization of these practices can be useful, adopting general approaches may overlook important nuance for unique patient populations. In particular, we are interested in how patients who live in a baseline unsafe situation conceptualize a “safe” discharge plan. Thus, our study aimed to understand the needs, perspectives, and priorities of patients experiencing homelessness as they prepare to leave the hospital.
Methods: Qualitative semi-structured interviews were conducted in 2023-2024 at a large urban, public, safety-net hospital in the Pacific Northwest. An interview protocol was created to solicit input from individuals regarding their definition of a “safe” discharge, their major concerns regarding discharge, and their experience communicating with the healthcare team in preparation for discharge. Any adult patient admitted to an acute care general medicine service who was living homeless (sheltered or unsheltered) was eligible. Patients with severe cognitive or mental health disorders that precluded consent process were excluded. Patients were approached, consented, and interviewed in English. Interviews were audio recorded, transcribed, and analyzed using principles of grounded theory. This study was approved by our institutional IRB.
Results: Patients experiencing homelessness shared their perspectives on discharge planning in three major themes: 1) basic needs, 2) barriers to stability, and 3) role of healthcare systems. These themes inform and build upon each other. Within the theme of basic needs, respondents identified the importance of physical survival: shelter/warmth, protection from violence, and treatment for major injuries or illness. They identified key barriers to stability that infringe upon these basic needs: loss of property such as mobility aids or legal identification, legal concerns such as the impact of previous incarceration record, financial challenges such as inability to access bank accounts, and other threats to independence. While many respondents were hopeful that the role of the healthcare system might be to assist in these issues, they also acknowledged the existence of significant resource constraints. Many reflected on the way that U.S. society views poverty and the impact of policy and funding to what is feasible by healthcare providers. Several participants were aware of interventions that the healthcare system puts into place to achieve better outcomes but noted these may still be out of reach when basic needs are not met.
Conclusions: We found that patients experiencing homelessness were overwhelmingly focused on achieving their basic needs, including physical survival and environmental stability. Current discharge processes should be tailored to individual lived experiences, especially with regards to housing status. Our data suggests that aspects of discharge planning that are “downstream” (e.g., medication reconciliation, discharge counseling, etc) may not be as successful without focus on foundational aspects of daily life. Prioritization to patient-centered needs is necessary.