No Respite for the Weary

Hundreds of people experiencing homelessness end up in the emergency room for serious illnesses or injuries each year. But after being discharged, where can they go?

By Erin Coleman

The entrance to the Denver Health emergency room. (Credit: Giles Clasen)

Jay Juno did not expect their gynecologist would agree to perform the laparoscopic surgery they received to confirm a diagnosis of endometriosis on July 28, 2017.

“Doctors are more likely to agree to surgical procedures if they know for sure you’ve got some place to rest,” said Juno. “If you’re homeless, you’re sleeping on a cot or mat on the floor—they don’t like that. No matter how much you assure them you don’t mind, they don’t like it. They don’t want to take the risk.”

Juno, who identifies as non-binary and transgender, says they were promised a respite bed at Catholic Charities’ Samaritan House to recover for four to six days following the surgery but, due to a series of snafus, was ultimately denied a spot. 

Samaritan House features a clinic, operated by The Colorado Coalition for the Homeless, which allocates 15 beds inside the shelter for respite use.  

“Samaritan House provides the space and we provide the medical services,” the coalition’s Chief Operating Officer, Lisa Thompson, explained. 

A client can use a respite bed for as long as needed, but Thompson estimates the average is about 30 days.

Although the coalition has a second location with respite services at Beacon Place, a transitional housing facility on West Colfax Ave. which houses another 15 respite beds, Thompson said, “There are not enough respite beds available to meet the demand.” 

The lack of beds is not unusual—people experiencing homelessness across the country face similar barriers in finding a place to rest while recovering from illness or injury. The gap in “medical respite care” is one culprit for continued high emergency room admittance rates among people experiencing homelessness. 

According to a study by the National Health Care for the Homeless Council, emergency room re-admittances were reduced by 50 percent when homeless patients were released to medical respite care rather than their own care. In Los Angeles, according to the study, that saved hospitals $3 million in a single year. In 2016, the council began research and on a set of standards for medical respite programs for homeless people in hospitals.

The precedent for follow-up respite care is well-known in Denver. A cost-benefit study for housing first programs by the Colorado Coalition for the Homeless helped prove the dramatic difference in a former patient having a stable place to recuperate — hospital spending dropped from $6,000 per patient to roughly $4,000 after entry into the housing program, with 50 percent of people showing a marked improvement in their health. 

But that relies on a place to go back to after surgery, which Juno and hundreds of others are left without. 

Upon being denied a respite bed at Samaritan House, Juno sought help from two additional agencies whose services they had utilized before. 

“A friend picked me up from the hospital after my laparoscopy and dropped me off at The Gathering Place,” said Juno. 

The Gathering Place is a daytime drop-in center for women, their children, and transgender individuals experiencing poverty and homelessness. A “nap bed” is available, but there is no priority given to those with specific medical needs according to Physical and Mental Health Program manager Erin Atencio. 

Jay Juno, who was left without a place to recover after a surgery for their endometriosis in July. Juno is reluctant to follow up on more surgeries they need after difficulty finding a place to recover after the procedure for their endometriosis. (Credit: Giles Clasen)

“We do not have medical staff on site and are not licensed to provide respite care. Porter [Hospital] or Denver Health can refer patients to Denver Human Services for motel vouchers,” she said.

“Then,” Juno said, “I called the Colorado Coalition for the Homeless. They said they couldn’t help with it. They [also] told me to use my own money for a hotel room.” 

Motel rooms are a common resort for homeless individuals to recuperate following medical procedures; however, the number that can be accessed for free through service agencies is limited.

“Ideally, respite would be pre-arranged with the hospital,” said Thompson. “Our primary partner for specialty care is Denver Health.” 

A Denver Health spokesperson said, “Care coordinators can request those beds for qualifying patients on the day of discharge, but they are subject to referral criteria and availability. We may assist homeless patients in identifying and reaching out to parties within their support network [who might] allow them to stay in a residence, even briefly.”

Denver Health also works with patients to provide access to phone and mail messages while in-hospital, and helps patients find programs, benefits and housing resources they may qualify for but be unaware of.

For general primary care, Colorado Coalition for the Homeless additionally operates the Stout Street Health Center. 

The Stout Street Health Center, which provides primary medical care for homeless patients. Stout Street hopes to have a respite facility with 50 beds built in the next few years. (Credit: Giles Clasen)

“Our Integrated Health Services include behavioral health and substance abuse treatment. We try to have as much as possible in one location,” said Thompson. 

In order to address the issue of patients not having a place to go after discharge, Thompson said the coalition would like to build a 50-bed respite facility behind the Stout Street Health Center within the next few years. 

Ultimately, Juno remained sleeping on a mat on the floor of the Samaritan House emergency over-flow shelter during the period of their recovery.

“I did not get good rest there and felt that I might get an infection in my incisions. I had two incisions in my lower abdomen from the surgery and lots of pain but nowhere to rest during the day,” they said. 

Juno is hoping to ask the same gynecologist for additional surgery to remove legions caused by endometriosis, but is reluctant after their experience in July. 

“Before, I was afraid to ask because I was still sleeping in [Samaritan House’s] emergency over-flow [shelter]; and, originally, [my doctor] didn’t want to do the laparoscopy in that situation. She agreed to do it when she thought I had a respite bed. Now, after that fell through, I’m afraid of going back to her to get more surgery,” Juno said.

In addition to endometriosis, Juno has been diagnosed with chronic gastritis, disabled degenerative disease, and bulging discs.

“I have pain every day,” they said. “Sometimes I can get a prescription for anti-nausea medication, but it’s hard to get anything for pain.”

 “[People who have homes] have more options to deal with their pain,” said Juno. “It’s not as important to them to be in good health, because they’re not having to worry about walking for several hours every day. I feel like being a homeless person is kind of like being a cheetah: you have to be in the best physical shape you can, because you don’t know when you’ll need to sprint, so to speak. If you have an injury, you can’t sprint. If you can’t sprint, you can’t get your food. You’re not gonna survive.”

But, despite feeling as though it is vital to be in good health, Juno has occasionally delayed going to the emergency room for fear of the treatment they would receive as a homeless individual. 

“Being homeless, I avoid ambulances. No matter how sick I am, I’ll put it off until I can get on the bus and go to a [hospital I trust], or I go to the trouble to walk, no matter how far away, just because it causes me so much stress to deal with that,” explained Juno. 

“We build trust with homeless patients by validating the difficulties they are experiencing, respecting their autonomy while offering support, and letting them know that they aren’t alone when going through processes that can take time before translating into tangible results,” said a spokesperson for Denver Health.

“The fact that you’re homeless -- it doesn’t help to convince anyone that you’re sane,” Juno said. “I feel like, when I go to my regular doctor, it’s a bit harder to get them to take my physical problems seriously. If you’re homeless, they seem to focus more on your mental health than anything. I’ve even had a few doctors tell me that maybe it’s my depression causing my pain. I was very glad when I got diagnosed with endometriosis, because I finally had some proof to say it’s not just in my head.”

Juno had been given a previous diagnosis of Irritable Bowel Syndrome, which stood until three colonoscopies, over the course of multiple years, all found nothing wrong with their intestines. 

“I was starting to think maybe I was imagining things,” Juno said. “I finally got a referral to an OB/GYN, and she said the only way to get a confirmed diagnosis was surgery. I was very lucky I was still able to get the surgery, even though I didn’t get respite care to recover.”

“We know that people who have been denied healthcare have developed mistrust,” Thompson said. 

That is part of the reason Colorado Coalition for the Homeless implemented the Health Outreach Program (HOP), which sends healthcare teams out into the community to see patients in neutral settings, such as shelters. “This also meets the general transportation needs of our clients, and provides flexibility in scheduling,” said Thompson. “We understand that not having transportation makes it difficult to follow-up with appointments. ”

“Being homeless can make it difficult for patients to maintain a regular routine, diet, timing of medications, or completion of follow-up care, all of which can create challenges in assisting them with care for chronic medical conditions,” said the spokesperson for Denver Health. “[Accessing healthcare] can be challenging for homeless individuals, who are motivated to start a process but have difficulty maintaining regular communication or finding and providing needed documents.”

 Juno feels as though the stress associated with accessing medical care has distracted from other pursuits, including their artwork, which is how they earn their income. The surgeries and procedures have not been lifesaving, but they have dramatically improved quality of life.

“If I feel better. I feel like I can do more—I have more energy to do housing applications and try to sell more of my paintings to make more money. It’s taken care of now, ‘cause I’m in the [transitional] program [at the Samaritan House]; but I wish there were more options in place if I didn’t have that—if I was back where I was before [in July], or if I was one of those people who slept outside,” said Juno. “There should be some place for people to go where they can get taken care of and get the minimum rest so they can still get the surgeries they need.” ■