Case Presentation:

A 72‐year‐old Hispanic woman with advanced Alzheimer’s dementia presented with failure to thrive. Vitals signs were stable. Body mass index was 17.7 kg/m2. The patient had severe contractures and multiple stage 2‐4 pressure ulcers over her sacrum, greater trochanters, and malleoli. Serum sodium was 148 mEq/L, bicarbonate 30 mEq/L, and creatinine 1.3 mg/dL. She was admitted for intravenous fluid resuscitation and wound care, with steady clinical improvement. Her interdisciplinary team soon encountered significant barriers to discharge. Her family had not accompanied her to the hospital after calling emergency medical services. According to an ex‐daughter‐in‐law, the patient was originally from South America and had immigrated illegally to the United States via Mexico two decades ago. The patient’s son had recently been deported, and there were no remaining family members in the country that could care for her. She had no insurance to cover skilled nursing facility placement. She did not qualify for inpatient hospice. Medical repatriation was explored, but the ethics team felt that she could not be safely discharged to South America. Extended family had no means of caring for her and no accepting facility could be located. No resources were available through her embassy in Washington, D.C. Nearly 5 months into her hospitalization, all disposition options had been exhausted. The hospital administration ultimately agreed to pay for nursing home placement, as it would offer the patient a less restrictive environment and be less expensive over the long term.


Hospitalists frequently manage complex discharges and strive to decrease length of stay. However, undocumented immigrants pose a particular challenge. An estimated 12 million undocumented immigrants reside in the United States, the majority of whom are uninsured. Hospitals have an obligation to treat all patients with emergency medical conditions under the Emergency Medical Treatment and Active Labor Act of 1986. However, discharge options may be limited once undocumented patients are admitted and stabilized. When caregiver needs are too high for family, these patients end up living indefinitely in the hospital – so‐called “permanent patients.” While insurance coverage is expected to expand considerably under the Patient Protection and Affordable Care Act of 2010, undocumented patients will still be ineligible for Medicare, Medicaid, and the state health insurance exchanges. This disparity is unlikely to disappear in the near future, even if Congress passes immigration reform authorizing a path to citizenship for illegal immigrants. In the meantime, hospitals will continue to receive little reimbursement for their care.


Hospitalists should engage case management supervisors and hospital administrators early when caring for undocumented patients with complicated discharge needs.