Skid row used to be the place where many homeless men and women wound up after being discharged from hospitals in Los Angeles.
Then Gabino Olvera, 42, was found crawling in a gutter in the downtown district, hours after his release from a nearby hospital. Paraplegic and mentally ill, he was wearing only a soiled cotton gown, witnesses reported. A catheter dangled from his body.
Media reports about Olvera's alleged "dumping" in 2007 led to a lawsuit against Hollywood Presbyterian Medical Center, which became a rallying point for homeless advocates. The case spawned a city ordinance that subjects hospitals to harsh financial penalties for “dumping” patients onto the streets, or sending them to shelters without advanced planning.
Now, as Sacramento experiences its own homelessness crisis, and amid accusations of "systemic" patient dumping by area hospitals, local leaders are considering a similar crackdown.
They are looking at the ordinance in Los Angeles, which in recent years has resulted in six settlements with hospitals and more than $3 million in civil penalties, as a model. The ordinance prohibits hospitals from transporting homeless patients to another location other than a health facility without the patients' written consent. The fines are used to fund homeless services.
The ordinance has established a set of checks and balances, and a demand for accountability from hospitals, said Los Angeles City Attorney Mike Feuer. It also has shined a light on the complexity of managing an exploding population of homeless people, many of whom have chronic medical and mental issues, when resources for housing and services are scarce.
Feuer, whose predecessor helped get the ordinance passed, has called patient dumping "unconscionable" and said it "will not be tolerated" in Los Angeles. "How would you feel if you were discharged from a hospital, taken some place and told to fend for yourself on the street?’” he asked in a recent interview with The Bee.
His office, which has a special unit for investigating dumping allegations, has aggressively pursued dozens of cases. Yet he acknowledged that improper hospital discharge still occurs in a city where homelessness remains rampant. Last year, a census counted 57,794 unsheltered homeless people in Los Angeles County, an increase of 23 percent from 2016.
Jennifer Bayer, vice president of external affairs for the Hospital Association of Southern California, said the ordinance’s passage a decade ago sent shock waves through L.A.’s medical community. Many perceived it as an overreaction to a few cases that were highly unusual or misrepresented to the public, she said.
Bayer said many homeless patients would end up in skid row after they were discharged from hospitals because the district for decades has had a high concentration of services for poor people.
California’s Health and Safety Code requires hospitals to have a discharge policy for all patients, including those who are homeless. Hospitals must make prior arrangements for patients, placing them either with family, at a care home or at another appropriate agency, the code says. The code does not require hospitals to get written consent from patients when discharging them. Legislation recently introduced into the state Senate, however, would require hospitals to get written permission from shelters before sending patients to such facilities.
Some patients ask to be released to the streets, Bayer said, and hospitals must honor those wishes. She pointed out that many homeless people suffer from addictions and mental illnesses and are sometimes difficult to place.
"This is so complicated," she said. “The system only works if the person is willing. There are many who refuse services and say, ‘I want to return to the streets.’ We know many of these people by name, and sometimes we just can’t help them."
Bayer said she is unsure whether the city’s crackdown on improper hospital discharges has resulted in fewer vulnerable people on the street. But it has had other positive effects, she said. “It got hospitals, shelters, law enforcement and others talking about the issue instead of everyone just trying to scapegoat one another,” she said.
Feuer said he believes the ordinance has been successful in holding hospitals accountable, but is only one important piece of a complex system built around caring for homeless people.
In Sacramento, elected leaders are grappling with their own complex system, one that is serving a growing population. A 2017 census counted 3,665 people living without permanent shelter in Sacramento County. Homelessness rose by 30 percent from the last time the transient population was counted in 2015.
For the first time, the city is operating a winter “triage” shelter that offers beds and services around the clock, and is considering making it permanent and opening two more. Mayor Darrell Steinberg has vowed to find housing for 2,000 homeless people during the next three years. The city and county are collaborating on a pilot program designed to steer homeless people who are heavy users of hospital emergency rooms into other health care services, mental health treatment and housing.
And following recent reports in The Bee of alleged “dumping” of homeless patients, city and county leaders have vowed to explore a measure that would levy fines against hospitals that engage in the practice.
A survey by the Sacramento Coalition to End Homelessness found that shelters and other agencies that serve poor people routinely receive recently released patients without prior arrangements having been made. Often, they have no beds or services to offer the patients, the agencies reported.
Sister Kathy Wood, a nurse practitioner who runs Clara’s House, a clinic for homeless people in midtown Sacramento, said she regularly sees homeless men and women, fragile and wearing hospital bracelets, lingering on the streets.
“When somebody has gone to the emergency room, and the ER doesn’t feel they need to be there anymore, and the person has no place to go, they turn them out to the streets,” she said.
Last week, she said, she and her staff helped a homeless man with painful sores on his feet who “had been put out by the emergency room at 10 at night” and was weak and unable to stand. Wood said he had no money to fill his prescriptions, so her agency paid the bill, and a local church got him a motel room for a night.
“This kind of thing happens all the time,” she said. “Hospitals will say it’s not their problem. But who in society is responsible for these people?"
An ordinance similar to the one in Los Angeles would help establish responsibility, advocates say. In advance of Sacramento possibly adopting its own local law, city officials are gathering information, they said.
County Supervisor Patrick Kennedy said he met last week with representatives of the city’s four major hospital groups in an effort to better understand their policies and procedures for discharging homeless patients. “We’ll go from there,” he said.
Councilman Steve Hansen asked Interim City Attorney Matthew Ruyak last month to investigate cases of homeless patients being left in city parks and at shelters. He also requested that the City Council’s law and legislation committee debate an ordinance addressing the “dumping” issue.
As of Monday, it was unclear whether an ordinance will be presented to the council in the near future. Ruyak referred questions on the matter to Assistant City Attorney Sandra Talbott, who said her staff has been in touch with investigators in Feuer's office, but that the issue has yet to be scheduled for consideration by the Sacramento City Council.
“We’re diligently working to get it scheduled for council discussion and consideration while we try to understand the needs of the community and the scope of the problem we’re trying to address,” Hansen said.
Hansen added that the city’s hospital networks have spent millions of dollars on homeless prevention efforts and described the organizations as the city’s partners.
Councilman Jay Schenirer, who chairs the council’s law and legislation committee, said he also has met with representatives of the city’s hospitals. “I’m kind of in a learning mode,” he said. “I’m not quite sure what the next steps are at this point.”
Bob Erlenbusch, of the Sacramento Coalition to End Homelessness, said the results of his survey and reports of recent cases of alleged dumping should prompt local government to act quickly. He questioned whether leaders are taking the issue seriously.
“It’s very troubling that the city and county are not moving with a sense of urgency, and are duplicating efforts in ‘researching’ the issue,” he said.
In addition to the ordinance, Los Angeles has employed other tactics to limit the improper discharge of patients. Anyone who witnesses what they believe to be a case of “patient dumping” can call a hotline maintained by the city attorney’s office. Those tips have prompted investigations and penalties, Feuer said.
But the most effective tool, he said, has been the city’s “Neighborhood Prosecutors” group, whose members are first responders, homeless services providers and others who are trained to look for signs of patient dumping, document them and report them.
“They are out in the field, in different areas of the city, and if they see someone suffering on the street and suspect a problem," they contact the city attorney's office, Feuer said. "They are invaluable to us."
In a few cases, Feuer said, medical facilities have agreed to change their policies and pay penalties of up to $1,000 for each violation in an effort to avoid a lawsuit. Civil lawsuits against hospitals have resulted in penalties of as high as $1 million.
Bayer, of the hospital association, said hospitals cannot help but be defensive in the face of punitive actions and sweeping accusations of “dumping” homeless people. But she denied that it is a systemic problem.
“If there is an egregious situation, of course we need to address it,” she said. “But does it happen every day, or 20 times a day? No."
Feuer acknowledged that the task of caring for people who are without money or shelter can be "very challenging." But he said he believes that hospitals can do better when treating the most vulnerable of people.
"From 10,000 feet, I can understand the reticence" of hospitals to the ordinance against dumping, he said. "But at the end of the day, these elements are doable. Every institution should be able to comply."