On the afternoon of June 12, an ambulance sent by Temple University Hospital's Episcopal Campus pulled up to Station House, a shelter for homeless men, with the kind of passenger Michael Hinson has come to dread.

Hinson noticed a disturbing pattern soon after he became president of SELF Inc., the organization that runs Station House and six other shelters, a year ago.  Some hospitals seemed to be trying to circumvent city rules by sending Station House weak and sick patients after 4 p.m., when a City of Philadelphia office that decides if people are well enough for shelters closes for the day. By ambulance, cab, and Uber, people would go from hospitals to Station House, which provides nighttime shelter intake for single men.

As a result, Hinson trained his staff to rush out and meet vehicles before they could deliver people to the shelter's parking lot off North Broad Street.

That June afternoon, the passenger was a paraplegic man in a wheelchair.  He was too weak to maneuver the chair himself or transfer to a toilet.  He needed multiple medications. For liability reasons, shelters are not supposed to take people who need hands-on care and cannot do for themselves what doctors call activities of daily living, like dressing and using a bathroom. Hinson said the city had told Episcopal the day before that the man was not appropriate for a shelter and needed to be in a nursing home.

A Station House intake officer sent the man back to the hospital.

Three hours later, at 6:45 p.m., Hinson himself was outside when the man returned, this time in a cab, along with a collapsible commode, a urinal, and three bags of clothes.

Episcopal had paid the cabdriver with a one-way voucher, and he refused to take the patient back to the hospital, Hinson said.  Trapped between the rules and his desire to protect the man's dignity, Hinson let him stay in the shelter overnight.  The city took him back to the hospital the next day.

"He's done nothing to deserve the broken system that we have or that the hospital has or the city has," Hinson said of his overnight guest.

There was a similar incident in March involving a Thomas Jefferson University Hospital patient in a wheelchair, Hinson said.  That man was so weak and out of it that he fell out of the chair. Station House sent him back to the hospital.  An hour later, Jefferson sent him back again, strapped to a stretcher.

"This is a person, a living person. Homeless, yes, but a living being," Hinson said.  "We are playing ping pong with real human beings."

Temple declined an interview for this story, instead issuing a statement that it works with "a wide spectrum of community partners … to assure appropriate discharge of patients whose medical needs no longer require acute hospital care." Jefferson said it could not verify an inappropriate placement on the date Hinson mentioned. Because of privacy rules, Hinson was unable to provide the hospitals with the names of transferred patients he thought were medically inappropriate.

The problem of how to care for what Hinson calls "medically fragile" homeless people who have few appropriate places to go once they leave a health facility extends well beyond these cases.  Homeless baby boomers are aging and they tend to be far sicker than better-off age peers.  At a time when government funds for the poor are under assault,  Philadelphia and other cities are grappling with how to keep the homeless, who tend to be heavy users of expensive hospital care, healthier as they age.  How to house them is a key part of the debate.

The city does not keep track of how many of its homeless people have significant medical problems, but Liz Hersh, director of homeless services for Philadelphia, said Hinson's concerns are justified.

"It's absolutely a problem," she said.  "We are 100 percent on the same page as Mike with identifying this as a problem."

Hinson kept a rough tally of after-hours attempts to place medically fragile homeless men at Station House from mid-January to mid-June. There were 13 cases involving hospitals, including Temple, Jefferson, Hahnemann University Hospital, Penn Medicine, Mercy Health System, and Crozer-Keystone Health System.  Patients were sent with diagnoses like lymphocytic colitis, severe diabetes, chronic skin ulcers, severe anemia and kidney disease, colostomy, and suicidal thoughts.  Four others came from Philadelphia's Office of Homeless Services, which asked Station House to take the residents at least for the night as a favor. One was a brain-surgery patient who had left the hospital before all of his skull was replaced.  Another was an 82-year-old man who spoke only Italian and whose landlord locked him out of his home of 26 years. During his two-week stay, the staff learned he had Parkinson's disease and early dementia. He wound up in an intensive-care unit.

The shelters don't always turn away people with serious chronic health problems, some of whom come in on their own.  "We have people here who we are constantly keeping an eye on because their diabetes is uncontrolled,"  Hinson said.

Station House accepted Michael Graham, 58, after he finished physical rehab.  His left leg was amputated below the knee because of frostbite and infection he got while he was living in an unheated house in South Philadelphia.  For more than a month, the shelter staff did its best to get Graham to doctors' appointments while he waited for a prosthesis.  Staffers were helping him get a copy of his birth certificate so he could get a SEPTA ID and, hopefully, Social Security income that would pay for permanent housing. The shelter, Hinson said, was not the right place for Graham, who also was depressed and not eating and drinking enough.  "He definitely needs a higher level of care," Hinson said.

Graham, a thin, gray-haired man, said he was eager to return to working odd jobs. "I can't do anything in this form, and I need help," he said in an interview.  He hadn't lost his sense of humor.  Asked where he'd like to live, he said: "The White House."

Three days later, he was back in the hospital and sick enough to need time in the intensive-care unit.

A new respite center

Hinson organized a roundtable discussion on the medically fragile homeless in May.  Jeff Deeney, a case manager at the Urban Affairs Coalition's Center for H.O.P.E. shelter,  said his 176-bed facility houses many such residents — people recovering from strokes or amputations or dealing with open wounds and heart problems — on one of its three floors.  Other residents sometimes help those more fragile take showers.  "We have our own participants becoming quasi nursing aides," he said.

Hersh thinks the situation has worsened during her two years in her job.  The city, she said, is trying to become better informed about how to get homeless people with medical problems into nursing homes or personal care homes more quickly, when they qualify.  She also hopes that medical providers and insurers will work with the city on the issue.  As it is, homeless people are big users of expensive medical care that might be avoided if they had stable housing and appropriate care before they got sicker. "We know that housing is a social determinant of health," she said.

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To relieve some of the pressure, Public Health Management Corp. in April opened a 20-bed, short-term respite center, Serenity Court, to replace an earlier eight-bed unit that was accessible only to people who could walk up a flight of stairs. The new center is meant for homeless people newly released from the hospital who need extra care as well as those dealing with chemotherapy, among other medical needs. It teaches people newly diagnosed with diabetes how to manage their blood sugar.

Hospitals — six now have contracts with Serenity Court — pay $250 per day for their patients' room and board. Medicaid covers clinical services.  The goal is to discharge residents to permanent housing with medical support.  PHMC also has 11 nurses that visit shelters and is considering expanding. And, it has a triage system that allows nurses to video-chat with shelter residents.

Although Serenity is not yet full, no one thinks it is big enough. "It's a big step forward for Philadelphia," said David Dunbeck, director of homeless and social service programs for PHMC.

What else should the city do?

Two days after he left Station House, Richard Sample — the paraplegic man who spent a night at Station House — wound up at Serenity Court. By the next week, he was strong enough to maneuver his chair through the halls at Serenity and the bathroom and he had an aide with him four hours a day.  Breathing problems and a bladder infection — plus an eviction — preceded his trips between Episcopal and Station house.  "I had an attitude, yeah," said Sample, 53, when asked how he felt about being transferred back and forth. Serenity, he said, had been "nice."

Temple had agreed to pay for his care through the end of that week, then he was supposed to go to a private shelter for a few days until the apartment Serenity Court's staff had found for him was ready. But Gina Gentile, nurse manager at Serenity, said Sample went to Hahnemann with chest pains. Then there was a problem with his apartment deposit.  While he was hospitalized the last week of June, Serenity was looking for another place.

Dunbeck said Serenity is meant for up to 10-day stays.  Not everyone will leave with a good housing situation.  "We have to accept the fact that we will have discharges that are not as positive as we would like," he said.

One question is whether the shelters should rethink the prohibition on hands-on care and either give their staffs more medical training or hire aides. "I think we're going to have to take these people," Deeney said at the May meeting.  He said the city may have to choose between having shelters full of older people getting inadequate care or accepting the situation and adding needed services.

"I think it would be smart to have a specialized shelter for this group," Dunbeck  said.

Hersh thinks the best solution is stable housing.

‘It’s a pretty dire situation …’

Medical problems among the homeless are almost certain to be a growing challenge for at least another decade, said Dennis Culhane, a University of Pennsylvania social-policy professor.  He said the youngest baby boomers, those born between 1953 and 1965, have dominated homeless populations since the late 1980s. Biologically, homeless people are much older than their chronological ages and are considered elderly above age 55.

"It's a pretty dire situation, to be honest," he said.

Culhane said that respite only forestalls the problem and suggests that homeless organizations apply aggressively for Social Security benefits and work with health organizations on suitable housing.

The hospitals that Hinson said had sent inappropriate patients after hours responded to the Inquirer's questions with short written statements that mostly boiled down to this: We're doing the best we can under trying circumstances.  Penn Medicine directly addressed the questions, saying it did not dump medically fragile patients and uses "all available resources to assist the homeless in a city where post-hospital placement is limited. … We routinely continue to care for patients while suitable discharge solutions are arranged, and we often provide clothing, transportation assistance, medications, food, and help applying for medical assistance to patients who are being discharged to shelters or other temporary housing."

Insurers, including government programs, don't pay hospitals for patients who no longer need hospital-level care. Some also penalize hospitals when their patients come back too soon for more care. Yet Michael Consuelos, a pediatrician who is vice president for clinical integration at the Hospital and Healthsystem Association of Pennsylvania, said finances rarely come up in discharge decisions. Patients should return to the community — and free beds for more seriously ill patients — when they're able, he said.  "I think hospitals are trying to do the right thing for patients," he said.

Joanne McFall, market president for Keystone First, which insures Medicaid patients in Southeastern Pennsylvania, said her company recognizes that social issues affect health and health costs.  "We would certainly be open to being part of any coalition of organizations that will come together to address this sort of issue," she said.

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Complicating matters is the fact that this can be a difficult population.  Medical problems often intertwine with mental-health issues, including addiction.  Homeless people may walk out of hospitals before they should, and may be unwilling to use their Social Security income — if they have it — for housing.  Many lack proper identification and the bureaucracies that can help them qualify for help move slowly. Behavioral problems often make the homeless unwelcome in group living locations.  Experts say individual supported housing tends to be more successful.

Hinson thinks it is time to take the problem more seriously.  "It's not one person's problem," he said. "I'm not at all trying to beat up on the hospitals or beat up on the city. … Unless it gets some attention, it's just going to continue to grow."

What other cities are doing

Philadelphia is not the only city grappling with this issue, though others have made more progress.

Boston has a 102-bed respite facility that takes patients similar to Serenity's and gets most of its funding from Medicaid.  It can also offer end-of-life care.  There is also a 20-bed center that provides less care than respite but more than a regular shelter.  A spokesperson said the respite center is always near capacity, while the step-down unit has a waiting list.

Phoenix's Circle the City agency operates one 50-bed respite program and is about to open a second.  It is supported with Medicare, Medicaid, and other federal funds.  Occasionally, a hospital pays directly.  It also has what it calls step-down respite in designated shelter beds.  Care there is provided by a team of nurses, a community health worker, and a mental-health practitioner who make rounds two to three times a week, more often if needed.

Los Angeles prohibits hospitals from discharging patients without a safe and appropriate plan for their housing. The city, which, unlike Philadelphia, has four public hospitals run by the health department, also has 1,300 interim shelter beds funded by the health department for people with behavior or physical health needs.  About 500 of those are "recuperative" beds for people who need on-site clinical services.  Funding comes primarily from Medicaid and a 1/4-cent sales tax voters passed last year to help the homeless.  Some hospitals pay a per diem.

After they leave, most patients go to permanent supported housing.  The city has apartment buildings with health clinics on site.

Cheri Todoroff, director of Housing for Health at the Los Angeles County Department of Health Services, said there are fewer homeless people in the public hospitals now, although the hospitals are still full.  "Now they're full with somebody who needs to be there."

A Rand Corporation study on the program found that it reduced overall spending.

The hospitals that Michael Hinson identified as having sent patients he considered medically fragile to his shelter in the evening responded with short written statements instead of making officials available to speak with the Inquirer about the pressures hospitals encounter when treating and discharging homeless patients. Their full statements are here:

Crozer-Keystone Health System:  Our discharge planning process takes into account all conditions and situations in the advocacy of every patient, including post-discharge destination. We have relationships with many community service organizations that help make patient transitions as safe as possible for those who identify themselves as homeless, regardless of time-of-day. Care coordinators at our hospitals consistently facilitate safe, stable and dignified discharges, with an arsenal of resources available to advocate for the most vulnerable patients.

Hahnemann University Hospital: "As an integral part of the health care delivery network within downtown Philadelphia, Hahnemann University Hospital is committed to delivering high-quality, compassionate care to all we serve. We have a long-standing history of treating the medically vulnerable and homeless population in Philadelphia. We have developed and nurture strong partnerships with local shelters, organizations and advocacy groups focused on addressing the health care and social needs of our most vulnerable and underserved community members. We partner with these organizations to find the best solutions for our patients and often we keep patients beyond what would be their discharge date to ensure patients are treated respectfully and with dignity."

Mercy Fitzgerald Hospital: "The Mercy Fitzgerald Hospital team takes very seriously its role in providing appropriate, quality care for our community members, especially those who are most vulnerable, as we have done in Delaware County for more than 80 years. While we cannot provide details about any specific patient's health or treatment, we have thorough procedures to evaluate each individual's needs.  At discharge, our care coordinators work with patients who self-identify as homeless to link them with community resources, such as designated intake centers that have after-hours availability."

Penn Medicine: "Contrary to the implication, Penn does not 'dump' medically fragile patients, and we use all available resources to assist the homeless in a city where posthospital placement is limited. The circumstances described do not reflect our discharge planning process and policies, which ensure that each patient is treated with dignity and respect. We work closely with homeless shelters and other social services agencies throughout the region to ensure that each patient has a place to go once they are medically stable and able to leave the hospital. We routinely continue to care for patients while suitable discharge solutions are arranged, and we often provide clothing, transportation assistance, medications, food, and help applying for medical assistance to patients who are being discharged to shelters or other temporary housing."

Temple University Hospital: "Providing care to vulnerable populations is part of Temple University Hospital's founding mission. Temple's clinical, social work, and care management teams collaborate closely with the patient and with a wide spectrum of community partners — including home health agencies, rehabilitation hospitals, skilled nursing facilities, shelters, and others — to assure appropriate discharge of patients whose medical needs no longer require acute hospital care."

A spokeswoman from Thomas Jefferson University Hospital said the hospital could not substantiate a medically inappropriate discharge on the date Hinson gave.  She added:  "Our first priority is the safety and well-being of our patients. We work collaboratively with our patients and their families on a comprehensive discharge plan, tailored to their individual needs, to ensure an appropriate transition of care after an inpatient stay or emergency department visit.  For those that require assistance with housing upon discharge, we collaborate with the City Shelter System of Philadelphia, as well as other shelters for non-Philadelphia residents. Once the appropriate shelter is determined and the patient information is approved and accepted by the Shelter Intake Center, Jefferson provides transportation and prescription assistance if needed. We encourage any patient to reach out if they have concerns about their care at Jefferson."

Hospital and Healthsystem Association of Pennsylvania:  "Pennsylvania's hospitals are open 24/7/365 and treat all patients. Hospitals continuously work to partner with the City of Philadelphia and private organizations to help homeless and medically fragile patients find the resources they need after their hospital care has ended.

"Hospitals make efforts to contact family members or a designated contact during their discharge process. In the event that these individuals cannot be reached, care coordinators and discharge planners work to connect the patient to available support services that can help with post-discharge chronic health care needs. Additionally, hospitals are working with community health workers (CHW), social workers, and other care coordinators to help patients navigate resources and appointments.

"Hospitals are working to address current social challenges through collaborative and individual projects to support outreach for food insecurity, housing issues, and community violence. And, as hospitals partner with the commonwealth and local governments to work to address the opioid crisis, hospitals also continue to advocate for increased government resources to further integrate behavioral and mental health services into a patient's care plan."