What Can You Do
With Respite?
Leslie Enzian, MD
Medical Director, Seattle-King County Medical
Respite Program
enzian@u.washington.edu
It Depends Upon . . .
 Local Resources
 Bed availability
 Facility
 Staff disciplines
 Funding stipulations
 Mission/philosophy
Seattle King County’s
Medical Respite Program
Respite Focus
 Short-term care for medically ill or injured homeless
patients
 Goals:
◊ Resolution of acute medical process
◊ Bridge the gap between hospitals and shelters
◊ Window of opportunity to engage into services
◊ Initiate the process of lifestyle stabilization
◊ Decrease hospital utilization and costs
Potential Roles
 Fill the service gap between hospitals
and shelters
 Fill the service gap between hospitals
and clinics
 Fill the service gap between SNF and
shelters
Acute Care
48 yo male presents to the ED with
alcohol intoxication and LLE cellulitis
and wound. Recommended to have 10
days of antibiotics treatment and daily
wound care.
What Can Respite Offer?
 Monitoring for resolution of infection
 Daily wound care
 CD counseling and follow up
 Mental Health Screening and care
TB Screening
 Vaccinations
 Housing Assistance
 Primary Care referral

Seizing the Opportunity to
Affect Long-term Change
52 yo male referred for leg wounds.
PMH: Chronic lymphedema with
recurrent wounds, HTN, Schizophrenia
SH: Homeless since 1970’s, sleeps on
mat at shelter, resistant to engaging
Discharge timing?
63 yo female presents to
ED with nausea, chills and
generally feeling poorly
 Can’t recall her medical history
 Chart indicates h/o schizophrenia and
sarcoid disease
 Off all meds, disengaged from all
care
SH: Staying in various emergency
shelters
Exam: 5X5cm irregular breast mass,
scabies rash, flat affect with delayed
responses to questions
Labs: Unrevealing
What Do You Do?
 Schedule patient for outpatient
mammogram/breast clinic follow-up?
 Admit patient for a inpatient work-up?
 Admit the patient to Medical Respite
for a diagnostic work-up and
formulation of a treatment plan?
Subacute Care in Respite
 Diagnostic evaluations for
disenfranchised patients
 Pre-procedural care for colonoscopy or
elective surgery
 Care during intensive treatment
regimens (chemo, radiation Rx)
 Hospice care
29 yo male in respite for
twice daily wound care
 Likes to sleep in, won’t get out of
bed for nursing visits--takes lengthy
cajoling
 Nurse has 10 other patients to see
and feels lack of time
What Can You Do?
 Give patient a warning then discharge next
time he declines to see the nurse
 Team intervention to review admission
agreements, negotiate a behavioral contract
 Impact: Tying up a bed from a patient that
might need, and cooperate with, care
 Behavioral difficulties
 Readmission criteria stipulations
 Defined behavioral management process
 Predetermined discharge dates
 Venue for discussion and support with staff
52 yo male in respite for a
mandible fracture.
 Client is angry and uncooperative
 Client uses physically intimidating
postures and makes a physically
threatening comment to nursing staff
 Staff and patient safety top priority
Safety in Respite
 De-escalation training
 Limit setting early
 Safety measures: alarms, coordinated
show of support, room set-up
 2 staff presence
 Zero tolerance for racial or sexual
harassment
 Venue for support, venting, discussion
46 yo male with EtOH
dependence, diabetes,
infected foot ulcers
 Sleeps in the woods
 In an actively abusive relationship
 Never consistently engaged in care
 Admitted to respite, received wound
care, continued to drink heavily, noncompliant with NWB, ulcers did not
heal
 Referred for primary care, mental health
 2 toe amputation recommended
 Transported to hospital but never arrived
for admission
 Few weeks later showed up from the woods
for a scheduled primary care appt.
 Wound was larger, dirty and grossly
infected, was off diabetic Rx, intoxicated
 Partial foot amputation
 Hospital calls to refer him back to respite
What Do You Do?
 Decline admission because of non-
compliance
 Readmit to respite?
Respite Course
 Drank daily across the street from respite
 Attended most respite nursing visits for
wound care, functioning in group setting,
blood sugars not wildly out of control,
mostly complied with NWB
 Supervising nurse daily reports of drinking
 Pt not discharged from respite, eventual
shelter discharge after considerable wound
healing
Focused Expectations
 Nursing felt pt sabotoged health and
respite care unsuccessful
 Admission was great success! Patient
did not get wound infection/leg
amputation
 Often can’t effectively fix maladaptive
lifestyle issues, but can prevent serious
complications from an acute process
How to Support Successful
Process?
 Difficult to witness self-destructive
behavior
 Clarify case goals with team
 Weigh impacts of various decisions
 Offer venue for venting, discussion,
support
 Training on harm reduction
Treatment Compliance
 Patient won’t take BP meds
 Patient discharged on a new diabetic
medication regimen and won’t follow it
 Do you contract then discharge these
patients? What is primary Rx goal?
 How can you maximize success and impact?
 Educate, engage, refer for primary care
54 yo female with history of
BAD with COPD exacerbation
 Off psych meds, unwilling to engage in
mental health care
 Not taking Rx prednisone and antibiotics
 Patient is agitated, angry and
uncooperative with respite care and
unresponsive to behavioral contract
 Patient is discharged by respite due to
behavior
The Patient is referred again
in 2 months for COPD
 Did you put the patient on a respite
bar list?
 If barred, how long would bar last?
 Could the patient be put on a
“Readmission Criteria” list stipulating
that she in stable on psychiatric meds,
engaged in mental health care and
contracts to cooperate with care?
45 yo male with pneumonia
and heroin dependence
 The patient admits to continued daily
heroin use
 Patient is behaviorally appropriate in
the respite space
 Attends all nursing visit except for one
What Are Your Options?
 Perform a urine toxicology screen and
discharge patient if positive
 Perform a urine toxicology screen and
contract patient to maintain sobriety,
discharge at next (+) utox
 Continue to engage patient in discussion
around use and options for treatment
 Implications of these various options
52 yo heroin dependent
patient referred for
abscess wound care
 Pt underwent operative drainage of
abscess and has a 20 X 10 X 5 cm
buttock wound
 Patient was on high dose methadone
and prn oxycodone in the hospital
 Hospital prescribes 30 pills of
oxycodone at discharge
 Questions? Potential problems?
How will patient’s
pain be managed?
 Do you ask the hospital to Rx higher
dose and quantity of narcotics at
discharge? (Implications)
 Do you ask hospital team to initiate a
pain service consult?
 Do you accept patient and send him to
an ED or clinic for pain meds day 2?
42 yo male with heroin
dependence referred
for pneumonia.
 Respiratory symptoms for 1 month
 Vital signs are stable and he is Rx
antibiotics
 He is independent in his ADL’s
 Do you have any questions for
hospital team prior to respite
admission?
Pneumonia Referrals
 Where is the infiltrate? Clinical
course? Does TB need to be ruled out?
 HIV and TB
CD4 counts < 200, CXR can be normal or
infiltrate could be in any location
Consider rule out TB prior to respite
admission unless clinical course clearly
acute pneumonia
39 yo female, poorly
controlled DM in clinic.
 Erratic BG monitoring
 Erratic BG readings ranging from 50’s
to 400’s
 Respite can offer:
Diabetic education
Feedback to provider on diet/compliance
Titration of meds to avoid complications
68 yo male in need of hip
replacement surgery
 Needs 2 wks of SNF post-surgically
 Surgeon won’t do surgery unless pt has
a recuperative place to go after SNF
 Nursing home won’t take him unless
there is place for him to go.
 Potential niche for respite
What Can You Do
With Respite?
 Acute medical care
 Care for chronic uncompensated or
decompensated problems
 Facilitate diagnostic evaluations and followup
 Pre-procedural care
 Care during treatments with associated
morbidity (XRT, chemotherapy)
 Care for clients not eligible for nursing
homes or are being discharged from SNF
What Can You Do
With Respite?
 Successfully care for behaviorally
complex patients
 Care for homeless high utilizers
 Linkage to primary care, CD treatment,
mental health treatment and housing
to affect long-term lifestyle
stabilization
“Respite has been a God send for me.”
Dave with a skin infection