As the winter’s cold drape descended in December, medical ailments drove Nancy and her 7-year-old daughter from Fullerton motel life into the degrading spiral of homelessness.
No longer able to work because of deep-vein blood clots in her legs, the 43-year-old and her second-grader bounced for two months from sleeping in the family car to shelters and finally in late January, when she was near collapse, to the West Anaheim Medical Center. Her daughter was placed in the Orangewood Children’s Home in Orange.
Nancy, who did not want her last name published, received care at the hospital. But while her condition had stabilized, her life outside the hospital had not. As her discharge grew near, it wasn't clear whether she had a safe place to go.
This predicament is not uncommon for homeless people who end up hospitalized. In recent years, the Irvine-based Illumination Foundation has worked to fill this need by providing transitional housing for people who are discharged with nowhere to go.
All the hospital need do is refer the patient to the program and agree to pay a nominal cost that is far less than the cost of a day in the hospital. But in her case, Nancy said, West Anaheim did not do that.
All she got was a bus pass.
“I was homeless, I was losing my child and I couldn’t sleep in my car anymore,” said Nancy. Only Illumination Foundation stepped in to rescue her with a place to recuperate.
Nancy's dilemma shows how an efficient, local program is being underutilized by the hospital industry, whose emergency rooms often end up with patients from the county's homeless population, which is more than 20,000, along with 22,000 children living in unstable conditions.
In 2007, the California Legislature passed a law sponsored by state Sen. Gil Cedillo (D-Los Angeles) that makes it a crime for hospitals to release people in precarious medical conditions without proper discharge planning.
In the immediate aftermath of the Cedillo law's passage, hospitals faced a challenge when discharging patients, who ended up caught in middle. Orange County has no year-round homeless shelter, and its cities are in many cases notorious for "not-in-my-backyard" attitudes toward homeless people, no matter what the situation.
In 2010, the Illumination Foundation began its recuperative care program specifically to meet this need. But while the 22 general acute-care hospitals in Orange County have contracts to utilize the program, records show that some seldom, if ever, do.
The program receives about 40 referrals a month from Orange County hospitals, said Paul Leon, the foundation’s chief executive and president. But he believes this is far below the countywide need.
“It behooves them to use us,” Leon said. He and others remain perplexed about the low referral numbers.
The cost for the Illumination Foundation’s recuperative program is $200 a day. A typical individual stays less than two weeks.
So with an average stay costing less than $3,000, it would seem a bargain for hospitals, which often must bear the substantial costs of care for homeless people because many aren’t eligible for county, state or federal health care programs. (Nancy was covered by the state Medi-Cal program.)
But when Nancy was discharged from West Anaheim Medical Center on Jan. 29, she was told that "they don't do referrals there."
West Anaheim Medical Center representatives refused to comment on the facility’s relationship with the Illumination Foundation’s recuperative care program but wrote in a statement that the hospital “is committed to treating all of its patients, regardless of circumstances, with high quality care and respect.”
Officials familiar with recuperative care program said West Anaheim Medical Center is just one of several hospitals that avoid using the program. The list includes Hoag Hospital facilities in Newport Beach and Irvine and Western Medical Center facilities in Santa Ana and Anaheim.
None of the other hospitals would respond when asked about referrals to Illumination Foundation. The Hospital Association of Southern California also declined to respond.
Other hospitals, however, regularly refer to the program, which has aided at least 1,000 people since 2010, Leon said. And an estimated 55 percent of those people have ended up being placed in permanent housing.
The program's supporters estimated it has saved hospitals in the county at least $3.2 million. Yet, they said, there is much room for improvement. A similar program in Los Angeles County also reported problems with under-utilization.
The Orange and Los Angeles county programs are similarly arranged. The National Health Foundation of Los Angeles, a nonprofit seeking to address gaps in health care for indigents, contracts with the hospitals in both counties. Then the Illumination Foundation provides the recuperative care under those contracts, with hospitals billed the daily rate.
Kelly A. Bruno, chief operating officer for the National Health Foundation, said the recuperative care program in Los Angeles also receives only about 40 referrals a month from hospitals. This despite her agency regularly seeking patient discharges from hospitals in both counties.
“I’m hard-pressed to believe they don’t know who we are,” said Bruno. “We try multiple ways reach out to them. They tell us they don’t have any patients in need of the program. We have to believe them.”
But those familiar with the lack of services across Orange County say what they see and hear on the street regarding need is far different.
Over the years, the operators of the Orange County Catholic Worker’s Isaiah House in Santa Ana have seen the need and the human costs. They provide regular meals to the homeless and shelter 50 to 80 women and children nightly.
“Hospitals used to put patients in a cab and send them to us,” said Dwight Smith, a Catholic Worker at Isaiah House. “But I screamed, yelled and threatened to report them to state authorities, so that has stopped.”
But because of the enormity of the homeless problem — particularly for men — people still intermittently arrive at his doorstep too soon after a hospital stay, Smith said.
Melissa Nicholas, also an Isaiah House worker, named an infamous case, instantly recalling the date of death: Dec. 30, 2010.
Her name was Martha Rose Keller, a 72-year-old with a long history of medical issues.
She had bacterial infections with wounds nearly to the bone. Sometimes she was seen trailed by hospital equipment. “She wrapped her legs in diapers, and then plastic shopping bags,” Nicholas recalled.
On Christmas Eve that year, she was found in distress at a bus stop. Emergency workers took her to Coastal Community Hospital in Santa Ana, where she died six days later.
Leon even recalled Keller from his previous days as a public health nurse working for the Orange County Health Care Agency. “Her kind of case was very tough,” he said. “She was hospitalized several times.”
Despite such difficulties, cases can turn out positively. “We’ve had a number of success stories,” said Leon.
Nancy remains on the road to recovery. In order to dissolve the clots, she must take blood-thinning medications, both injected and oral, for weeks. This therapy also requires regular blood tests to chart the clotting time of blood to adjust the medications. Such a regime can be taxing even for someone living a comfortable life.
“We need more programs like recuperative care,” she said.
Rex Dalton is a San Diego-based journalist who has worked for the San Diego Union-Tribune and the journal Nature. You can reach him directly at firstname.lastname@example.org.