The hallway to the small shared room at a Bethany nursing home where Teddy, 62, has spent most of the past two years is dim and an ammonia-like scent hangs in the air.
Machines whir outside his door. A wheelchair sits next to Teddy’s bed, the only piece of furniture besides a dresser. He leaves the room for meals and comes back to watch a compact TV that sits at the foot of the bed. Teddy rarely gets visitors. The Frontier and Curbside Chronicle are only using Teddy’s first name to protect his privacy.
His former case manager, Sherry Helsel, said the nursing facility is a best-case scenario for Teddy, who suffered a traumatic brain injury years before, leaving him with severe memory loss and unable to walk without assistance. After his last family caregiver died, he bounced between shelters and health care facilities.
When he was discharged from an Oklahoma City hospital in July 2021 after a roughly two-week stay, hospital staff had him dropped off at a local homeless shelter with adult diapers and a walker, Helsel said. Lying in his nursing home bed in April, Teddy said he didn’t remember his time experiencing homelessness.
“He didn’t ask for any of this,” Helsel said after visiting Teddy, pausing to dab at tears in her eyes. “Life happened to him, like it does to all of us. But a lot of us are fortunate, and we have resources to help us when we’re in this situation.”
In Oklahoma City, there are few good options for people experiencing homelessness who are discharged after a hospital stay but still too sick for the city’s already strained shelters.
Providers agree a medical-level respite facility would expand care options to more people, but no medical respite program exists in Oklahoma.
Hospitals mostly provide short-term care for severe illness or injury. The state’s only non-medical respite center for people experiencing homelessness, the Cardinal Community House in Oklahoma City, doesn’t provide care for people with intensive needs like Teddy, who can’t do basic tasks on their own such as going to the bathroom or bathing.
Oklahoma County’s Social Services Department has a seven-bed contract with Cardinal Community House to give case management and respite services to people experiencing homelessness after they are discharged from area hospitals. More than half of the applications the county has denied are because a person had higher care needs than the respite center could provide, according to county data.
Meanwhile, the need is growing. Statewide, discharges to homelessness from hospital emergency rooms increased nearly 45% between 2020 and 2022. Emergency rooms discharged about 13,000 people to shelters or the streets during that time, according to provisional data from the Oklahoma State Department of Health.
A state task force had been studying the problem and looking at ways to use Medicaid funding to expand care options in the state, but efforts stalled after Gov. Kevin Stitt disbanded the Governor’s Interagency Council on Homelessness in April. The governor’s office did not respond to requests for comment.
The state is also facing a nursing home staffing shortage, making bed space limited at long-term care facilities. People who rely on government benefits to cover care costs have an even harder time getting a bed since state reimbursement rates are often lower than the cost of care.
Cindy Maggart, Mercy hospital’s director of post-acute care services, said her team faces an up to 90% denial rate when trying to get patients who need long-term care into nursing homes. Hospital administrators said it is part of their job to find facilities where patients can get the care they need. But financial barriers, criminal background checks, delays in gathering important documents and fears about losing personal freedom can keep people from some placements.
Without access to additional care options, individuals end up discharged to the street or to local shelters that aren’t equipped to care for them.
“People are being discharged to the street or to the shelters because we’re in this really hard spot of what do we do with this individual, especially those who can’t perform their activities of daily living,” said Racheal Singley, director of Catholic Charities’ case management team serving respite center clients. “There’s nowhere for them to go, and it’s very difficult sometimes to see that.”
A little more care
Helsel was in her office at the Homeless Alliance, a nonprofit that runs a day shelter in Oklahoma City, in July 2021 when she got a call from a social worker at SSM Health St. Anthony who was looking for someone to take Teddy after the hospital discharged him, she told The Frontier.
SSM Health said it couldn’t comment because of patient privacy laws, but agreed that the community needs a place for individuals who are too sick for shelters but don’t require hospital care. SSM Health was the first local health system to contract with the respite center in early 2022.
The first question Helsel had for the hospital staffer was whether Teddy could do basic daily living tasks on his own like dressing, eating and going to the bathroom. The hospital worker said yes, Helsel remembered.
After the hospital dropped Teddy off at the Homeless Alliance, Helsel took him to the City Care night shelter and planned to pick him up on her way to work the next morning. Teddy wouldn’t be able to navigate the mile walk back to the Homeless Alliance day shelter on his own.
Every night, City Care fits as many people as possible into its 140-bed facility, sometimes going over capacity. On a daily basis, the night shelter sees people who have open wounds, are incontinent or have serious mobility issues, said director Shawn Loyd.
In the two years since the shelter opened in April 2021, there have been roughly 1,100 ambulance transports from the facility to a local emergency room, according to data provided by EMSA, Oklahoma City’s ambulance operator.
Staff frequently have to act like nurses aides, Loyd said, showering people or changing adult diapers. But they aren’t trained to do those jobs. Nursing homes and assisted living facilities, which provide those services, have to follow strict guidelines and regulations that the shelter isn’t equipped to handle.
“We have multiple people that have unmet health care needs, and we still have quite a large number of folks that are walking in the door that are just discharged from a hospital and could use a little more care,” Loyd said.
City Care tries to accommodate those it can, but some people are transported back to the hospital while others can’t stay because of safety concerns.
When Helsel returned the next day to pick up Teddy, shelter staff told her he couldn’t come back because he wasn’t able to safely perform basic self-care tasks. Case workers arranged for Teddy to stay at a different area shelter, but he was discharged again because the shelter couldn’t care for him either.
Helsel said she tried to get Teddy into Cardinal Community House, but he didn’t qualify because his care needs were so high.
Cardinal Community House offers a place to recover and receive case management for people who were recently discharged from a health care facility who no longer need hospital-level care but still have ongoing medical needs that would be made worse without somewhere safe to stay. Clients must be able to manage their own personal care and the center does not have its own medical staff to provide care to clients directly. People are usually limited to 30-day stays at the center, unless the contractor paying for their bed — typically a hospital — approves an extension.
When Cardinal Community House opened in March 2021, it filled a hole in Oklahoma City’s health care discharge system, providers said. People that receive care there are less likely to wind up back in the hospital, and collaboration between hospitals and shelters has increased. But the center has limited funding and is still trying to find new health care groups to partner with.
“The respite center fills a need, but I think that it has illuminated that there’s still a gap,” said Meghan Mueller, associate director of the Homeless Alliance.
The Homeless Alliance paid to put Teddy into a hotel while Helsel applied for federal and state benefits and searched for a facility that would accept him.
Helsel and two other staffers visited Teddy multiple times a day. He couldn’t prepare food for himself or manage his medications. Helsel called other shelters, adult protective services and nursing homes. But Teddy’s applications for benefits hadn’t been processed so he had no way to pay, and he wasn’t approved. After several weeks, Teddy was back in the hospital because of issues with managing his medications.
The hospital, along with Helsel and Loving Care Management, an organization that helps place individuals in nursing care, eventually found a facility that would accept Teddy in August 2021. He’s still there today.
Helsel brings him bags of Reese’s peanut butter cups and cases of Dr. Pepper when she can. Teddy’s life is small, she said, but a nursing home is safer than living on the streets.
Looking for relief
So far, more than 250 individuals have received services from Cardinal Community House.
Local hospitals and Oklahoma County’s Social Services Department pay the center to provide a private room, daily meals and case management services for patients that have been accepted into the program. Case workers help clients find permanent housing, apply for benefits and gather personal documents.
But unlike a medical-level respite program, Cardinal Community House staff can’t provide much direct health care to clients. The center and hospitals can coordinate follow-up appointments with doctors, bring in some home health aides for certain clients, store medications and provide transportation.
Mercy hospital, which pays $135 per day for each of its five contracted beds, has kept its beds full with 20 patients since the contract went into effect in November 2022.
“It’s that really great pivot point for patients that have really just been through the trenches, and they just need somebody to help them navigate that,” said Cindy Maggart, who directs post-acute care for the hospital. “And instead of bouncing around from shelter to shelter, this provides great continuity for them.”
But the hospital still sees a large number of patients who don’t qualify for the respite center.
In Oklahoma City, the number of people experiencing chronic homelessness — people with disabling conditions that have been homeless for a long period of time — has nearly doubled since 2017, according to counts done by social service providers. These groups tend to have high medical needs and frequently visit emergency rooms.
Medical respite would increase the range of clients that can be accepted into care programs because health care staff would be employed by or partnered with programs directly, available to do multiple check-ins a day for all clients and help people do care tasks like going to the bathroom or getting dressed.
“It’s in everybody’s benefit for respite shelters to exist,” said Kelli Ude, director of Cardinal Community House. “How the most vulnerable of our citizens are doing deeply impacts every one of us. With resources like this, we prevent poor outcomes, and we have a healthier community.”
Cardinal Community House and City Care are both working on plans to develop medical respite facilities in Oklahoma City, but are still searching for funders. Costs have stopped the groups from creating medical respite programs so far.
Lindsay Cates, a homelessness initiatives coordinator for Oklahoma City, said while there are no plans to use city dollars to help fund respite now, officials may decide to get involved later on.
Oklahoma’s Medicaid program can cover some high-needs care, said Bobbi Six, the congregate settings project coordinator with the State Department of Health, but it requires a doctor’s order and a permanent place of residence. Getting approval takes about four months, she said. But since the respite center doesn’t directly provide its own health care to clients, it can’t currently receive any insurance payments.
The state could get a waiver from the federal government to provide some funding to medical respite organizations, but efforts to do so are less coordinated after the statewide homelessness council was dissolved. The federal Centers for Medicare and Medicaid Services approved the first state waiver for funding medical respite in California this year and called respite programs “cost-effective and medically appropriate alternatives” in a January 2023 letter.
Some hospitals have said they may be interested in participating in a medical respite program, which would likely be a financial benefit to them as individuals stop needing to rely on expensive emergency room visits, administrators said. Hospitals could provide funding or staffing.
“We would fill it up and keep it full,” Maggart said.
By the end of April, Helsel was preparing for her last day as a case manager. The grant that funded her position was related to the pandemic and expired. She spent her last day visiting clients.
During her two years at the Homeless Alliance, many of Helsel’s clients tried to get care at hospitals and were discharged without adequate resources. Expanded respite programs would have helped, she said.
As Oklahoma’s population ages, Helsel said she’s not sure the state is prepared. A lack of affordable housing options, low access to mental health care and staffing shortages at care facilities are all serious barriers that have not been addressed.
“There’s not enough funding for care for people with high-level needs,” Helsel said.