Table 4.

Implementation barriers and facilitators: examples from key informant interviews.

Implementation barriers
Limited community resources	“We still are dealing with lack of resources in order to satisfy the law. I think even after SB 1152 was [put in place], it was as if nothing had changed. We still have the same limited women’s shelters, men’s shelters. [We need] more recuperative care [and] more long-term housing options… those options should have been available as of January 1st, 2019. It’s almost like having family come over for Thanksgiving but all you have is Top Ramen and half a jug of water in your refrigerator. Like, okay. Well, do what you can, you know.” – Clinical Social Worker, non-profit, LA County “Eureka has [a] psychiatric hospital…and I think it’s only 16 beds. However, it’s the only one from Santa Rosa to Brookings, Oregon. That’s four hours in each direction. There are no towns around us to absorb it. It’s all wilderness between north, south, east, then there’s the ocean.” – Social Worker and Nurse Case Manager, for profit, Humboldt County “For someone who is experiencing homelessness, those patients are just much, much harder to find a place for, because facilities don’t want to accept them, unless they know in the beginning that there’s a discharge plan waiting for them at the end of their course there.” – ED Social Worker, non-profit, LA County
Limited hospital funding	“So, it’s like one size does not fit all and small rural facilities, especially like ours, we’re a privately owned for-profit. We ride the ragged edge of financial disaster every single day and sometimes we can’t afford to buy [even] angiocaths. So, kick a little money our way… And the cudgel that you want to beat these large urban centers with, is just like Godzilla’s footprint on the small rural facilities.” – ICU/ED Nurse Manager, for profit, Humboldt County [SB 1152] has caused hospital more money in some way because we do the increase in number of meals, each meal may cost $10–$12 because it has to be a meal, not a sandwich. So, you know, and then when you multiply by 10 to 20 and 365 days, that could add up.” – ED Physician Administrator, county, LA County
Limited staffing	“But I would say one of the main limitations is just the fact that we don’t have 24-hour social work and case management… and there are only two acute medical social workers. They can’t always call when we have a homeless patient who’s discharging.” – Clinical Social Work Supervisor, non-profit, LA County
Limited state support	“[The] law is up to interpretation…it will be nice to clarify if this was intended for inpatient [discharges]. And then what are some of the things that need to be done from the emergency department. What about urgent care, what about from the clinics[?] Clinics…they don’t follow any of these [SB 1152] rules, or even urgent care, while the patient goes to [the] ED then [for us] to do things, including making arrangements for transportation and document all this need. So, I think the clarification of the law would help.” – Emergency Physician Administrator, county, LA County “I guess for me personally, a better understanding of, if someone doesn’t want medication, are we still obligated to get it to them? There are some questions we still have…where I get tripped up a little bit is like, well, how much are we supposed to bend over to get someone medication if they don’t want it? Can we just say, we don’t need to do that if they don’t want it? That’s the one hiccup that I get chipped up about.” – Clinical Educator, university, LA County “Well, maybe a toolkit of ‘Oh, these are options’ could have been [helpful]… It’s like, ‘Here’s what hospital A is doing and has done, and this meets our criteria. Are you doing this? Here’s some ideas.’ Something like that probably would have been helpful.” – Manager of Care Transitions, non-profit, Humboldt County
Implementation facilitators
Strong community partnerships	“We continue to have strong partnerships with the local rescue mission and a number of sober living houses and places like that, where patients could go at discharge.” – Nurse Manager, non-profit, Humboldt County “We’ve also established some really great relationships with community entities that really worked to address homelessness in the South Bay. We have one entity called Harbor Interfaith Services that recently opened up two Bridge Home sites, which is interim housing. They’ve been really diligent in making sure to keep in contact with us to identify some of our homeless individuals that are constantly coming back to the ED and the hospital. That way they can get them into the Coordinated Entry System and get them connected to long-term housing…They’ll come to the hospital. Assess the patient. Put them in the Coordinated Entry System…Then we can potentially have them discharged to that interim housing. As opposed to discharging to an emergency shelter or back to the streets.” – Clinical Social Work Supervisor, non-profit, LA County
Donor funding	“There should be more support…we’re lucky that we’re at [this hospital], and [we have] funding for us to pay for recuperative care. We’ve been using recuperative care to place the homeless, but the hospital’s paying for that. For the hospitals that don’t have that much money, they don’t have that luxury.” – Homeless Care Coordinator, university, LA County
Hospital staff for PEH	“Everybody should have a point person that’s building the relationship and really has the bandwidth to get out there for the resources. Adding [the homeless care coordinator] has been the best thing that’s happened for us. Just all around, because he’s been able to make the relationship within the community, and really tell us, ‘No, this is an existing resource, this doesn’t work,’ so we’re all in touch and not out of date.” – ED Social Worker, university, LA County

SB 1152, California Senate Bill 1152; LA, Los Angeles; ED, emergency department; CNO, chief nursing officer; ICU, intensive care unit.