Against medical advice, vulnerable patients are leaving hospitals too soon. Who’s to blame?

CATHY WURZER: This is Minnesota Now on MPR News. I'm Cathy Wurzer. Most of the time, doctors and patients agree on when it's time to leave a hospital after a stay. But sometimes, a patient decides they want to leave right now. For one Twin Cities hospital, M Health Fairview, only a small share of its patients leave the hospital early against their doctor's advice, but that number is five times higher for people who use opioids or meth and 10 to 12 times higher for people of color with those addictions. That's according to new reporting this week in the Sahan Journal.

We're going to hear from a doctor working to reverse that trend. Dr. Ryan Kelly is with us right now. He's a general medicine hospitalist, a primary care physician, and also treats opioid dependence at the Community and University Health Care Center. Welcome, Doctor.

RYAN KELLY: Hi. Thanks, Cathy. Happy to be here.

CATHY WURZER: I'm curious. Why would folks with drug addictions check themselves out of a hospital early?

RYAN KELLY: The most important question is, just in general, who has the resources to be away from real life when they're in the hospital, right? If someone doesn't have someone to watch their kids, if someone has real-life things happening, they have to pay their bills-- that's tough to do when you're in the hospital. And so I think that's challenge number one for a lot of people. But when you throw in substance use, lack of education across health care providers across all hospitals, that really adds to the stigma and bias and the trauma people feel. And I think that's a part of the challenge.

CATHY WURZER: Does the fact that sometimes friends and family might not be able to visit-- does that play a role in any of this?

RYAN KELLY: Yeah, especially with COVID, right? All hospitals across the country handled COVID in similar ways, where we were worried about people coming to visit and getting exposed. And there's a long time where no one was allowed to visit, which made the hospital even more of a scary place.

But we have a lot of people that-- at the University of Minnesota, people are transferred here from far away, and family aren't able to visit. We also have people who are local, who don't have-- their family just doesn't have the resources to take time off work and come visit. So that definitely impacts things.

CATHY WURZER: I wonder this-- my doctors not discuss the risks of leaving early, because there can be some serious risks?

RYAN KELLY: Definitely. I think the challenge is, do health care providers-- when they're meeting a patient, do they have the training to realize that being in the hospital is a hard place to be? And I think most providers-- there's enough other things that we're taking care to help the person heal that that's not on everyone's radar.

But a lot of times, the reasons that people leave come up later in the day, right? Oh, I don't have child care. Or, oh, I've got to go pay this bill before 5:00. Or, oh, it's nighttime. The day team who knows me isn't here. The people at night don't know me as well. It's more traumatizing, et cetera. And so a lot of times people leave, that decision is so sudden, there isn't a great deal of time to have that conversation.

CATHY WURZER: Mhm. And maybe for folks who might not understand the situation, what's generally happening in an emergency department at this point? These are places where most people tend to enter the system at that point, the ER. So what's happening there that might make this situation a little more fraught for patients?

RYAN KELLY: The first thing I've realized by having the right mentors, working with people with lived experience, is understanding that seeking care in general is a challenge. A lot of people don't have the luxury to make it to a scheduled appointment. If you don't have transportation, a phone, housing, if you don't have family support, if you don't have child care, a lot of times, you can't make it to a scheduled clinic appointment. The emergency department is open 24/7, however. That's why a lot of people-- that's their only option.

If people are going to an emergency department, and, across the country, hospitals are so full that people are in the waiting room before they can even be seen in the emergency department for a while. And so if someone has a substance use disorder, they're coming to the ED to seek help, but they're in the waiting room so long that they go into withdrawal and can't stay because of how they feel, that's definitely a challenge.

And then if someone does get into the emergency department, they still need to have space upstairs in the hospital. And so there's just a lot of challenges these days with how hospitals in general are filled to capacity.

CATHY WURZER: Wow, that's a lot going on. I wonder, then, is it possible that the traditional scenario, as you just outlined-- traditional hospitals are not the right fit for everybody? And if so, what about maybe some sort of a new model, perhaps?

RYAN KELLY: Question number one, when someone's in the hospital and they're physically doing better but they need interventions that, let's say, they need weeks of IV antibiotics, or let's say they need physical therapy or wound care or something that doesn't have to be done in the hospital but could be done at a nursing home or a transitional care unit, or they could be done in their own home-- there are systems to help get people to those more affordable options and increase space in acute care hospitals.

But at the same time, if someone is unhoused, if someone has a history of substance use, a lot of times, those aren't safe options. And so different health care systems across the country, including the Twin Cities, are trying to create models where if someone is unsheltered, can they go to a place where they can have a nurse come and do dressing changes for their wounds? Where they can have someone come and help with IV antibiotics? Someplace that's not a hospital but someplace that provides housing while they get these medical resources brought to them?

And so at the University of Minnesota and at M Health Fairview, we have a relationship with a respite shelter called Our Saviour's, which does exactly that. And there's other hospitals in the Twin Cities that are working on that. But I think in more rural areas, Minnesota-- I think that's definitely a challenge as well.

CATHY WURZER: Have you seen any other models in other parts of the country that are interesting? Any other interesting work going on?

RYAN KELLY: Mobile models are really making a big impact. If you can bring health care to people and, over time, build a relationship, find out what resources they need for health to no longer be a luxury they can't focus on but something they can focus on, at that point, that person then-- once they have transportation or housing, then more traditional health care settings, like a primary care clinic, becomes more feasible.

CATHY WURZER: How did you get involved in this work? You are a hospitalist. You see all kinds of different cases. You could have just kind of continued on and done your job, but you're doing some interesting work here. What was the spark?

RYAN KELLY: So when I finished my training at the University of Minnesota in internal medicine and pediatrics, I started at primary care for adults and kids at the Community-University Health Center, like you mentioned. And I was a half-time medicine hospitalist at the University Medical Center.

And then in 2015, our clinic got a grant to start a Suboxone clinic. Suboxone, or buprenorphine, is one of the main medications to help people with opioid dependence. And that little bit of education really opened my eyes to the challenges people with substance use disorders face seeking health care.

Back then, the University of Minnesota didn't have a robust addiction support program for people who were admitted to the hospital. And so that's been my main focus for the past couple of years with my colleague, Dr. [? Pham, ?] to improve the health care people receive in the hospital to try and figure out ways to improve their health and keep them in the hospital until they're medically ready, and try and, like you said, think outside the box to figure out ways to get people their care in whatever way fits their lifestyle.

CATHY WURZER: And thinking that if you get better care, perhaps that does go away toward helping a person overcome the addiction in due time?

RYAN KELLY: Exactly. And so when it comes to opioids, someone is able to use in a safe way, know what they're using, know their dose, not use by themselves, and have access to naloxone, they're protected from overdose. Unfortunately, the way opioids work, anyone taking an opioid for more than a couple of weeks-- they get tolerance, meaning the dose doesn't work the same anymore. So whether this is something that they're getting prescribed from their doctor after a surgery or a teenager who was using their grandparents' opioids on the weekends for fun-- they get tolerance. They have to use more. It gets expensive. And so injecting-- they can use a smaller amount.

And so anyone who is injecting, if they have safe supplies, if they have access to clean water and soap to wash their hands, if they are able to use in a safe way, we prevent HIV. We prevent hepatitis. We prevent bacteria from the outside getting into our body and leading to complications that lead people to be hospitalized. So if we can help support someone until that point that they're ready to seek care, we keep them alive.

CATHY WURZER: Wow. Interesting work you're doing here, Doctor. Thank you for doing it. Thank you for your time today.

RYAN KELLY: Well, thank you so much for this opportunity.

CATHY WURZER: That's Dr. Ryan Kelly. He's a general medicine hospitalist, primary care physician, also treats opioid dependence at the Community and University Health Center. You can read more about this issue in an article in Sahan Journal. That's an online news source covering BIPOC and refugee communities across Minnesota-- sahanjournal.com.