Hospitals must walk a fine line between providing care mandated by federal law and keeping staff, patients, visitors and the public at large safe. The Emergency Treatment and Labor Act (EMTALA) mandates that when a person presents at the emergency department, the facility must diagnose that person and provide emergency medical treatment, regardless of the patient’s ability to pay.

Respect, Non-Judgment Are Key

Needless to say, as a result of the sensitivity of these types of situations and the legal requirements, it’s quite easy for security staff and clinicians to make mistakes when homeless patients first come into the emergency room. A non-judgmental attitude and a service mindset can make the intake process more productive, says David LaRose, the director of safety, security and emergency management at Lakeland Regional Medical Center.

“The wrong approach I’ve seen is to initially confront the individual with an almost hostile or defensive mindset of, ‘Who are you? Why are you here?’ and ‘Get off of our campus,’ rather than clearly asking, ‘Can we help you?’” he says. “Find out the facts before you aggressively encounter someone because you assume they’re homeless. I’m not here to judge. Everyone is free to choose their path, and we may not have chosen the same path, but I’m still here as a humanitarian providing a service.”

Something as simple as calling the person by their first name helps convey respect. Verbal de-escalation and crisis intervention techniques can also calm a tense situation, as can the friendly demeanor of a designated security officer who acts as an ambassador in the waiting room. Grayson applied this approach with one of his hospital clients.

“We picked somebody who was fairly large and was one of the friendliest people around, and we gave them some special training to monitor body language with the idea that if they saw somebody who looked agitated, the [ambassador] would sit down and have a conversation with the person to talk it out,” Grayson says. “They were also trained to be able to pick up on symptoms of illness. If a person had pain that was radiating down their left arm, the security officer would be the one to talk to the charge nurse to let them know there was a change. It was a sort of preemptive strike for building in the human touch. We set it up for everybody, but the only thing that could be different with the homeless is the psychological vulnerability that may make some within that group more likely to act out.”

Although all of these techniques have been proven to work, staff should also be aware of past behavior of individuals who have visited the hospital previously, advises Glasson.

“There is a fine line between making sure history does not repeat itself and automatically making the assumption it will,” she says. “A number of facilities today have some type of alerting system in place to give people a heads up that maybe there have been behavioral issues with an individual in the past. I don’t think that is discriminatory, as long as it’s based on objective criteria. It’s the same as if somebody had a heart attack in the past. You don’t want to ignore that, but you also want to make sure that when they present, you rule out other causes.”

Overworked Staff, Crowded Waiting Rooms Pose Problems

Another challenge for hospitals, especially busy ones in major urban areas, is the fact that ERs — and hospitals in general — can be overcrowded, and medical staff are overwh
elmed.

“In my opinion, larger organizations tend to function in a vacuum with every patient that comes in,” says ODS Health Care Security Solutions Health Care Division President Lisa Pryse. “We’ve got hundreds of patients who are in the queue to be seen, and we deal with what presents at that moment. It’s so unfortunate when it comes to your homeless populations because in most communities, there are numerous organizations that will work with hospitals to assist with this over-arching problem and not just the symptoms in the emergency department. I think sometimes there aren’t enough hours in the day or enough money for a hospital to have a liaison to figure out what else we can do to assist these patients.”

The issue becomes even more apparent when the hospital is dealing with “frequent flyers” — homeless patients who visit the same facility over and over again. In Sheet’s case, his organization had one person who was admitted 176 times in 10 years.

“There needs to be that institutional push to collaborate with the local health department and behavioral health agencies to identify what resources are available and redirect these folks so they’re not eating up the valuable resources in our emergency department or behavioral health units that should be available for those who are chronically ill,” he says.

Hospitals Must Collaborate With Other Agencies

Indeed, all of the hospital security professionals Campus Safety interviewed for this article agree that collaboration among a wide variety of internal and external stakeholders is the key to appropriately managing homeless individuals.

Hospitals should have a plan for the humane treatment of the homeless, with liaisons/ombudsmen and/or social workers who work with them to understand their challenges and connect them with community resources. Security staff as well as clinicians should also be trained on how to make referrals. They should know where the shelters are located and where the homeless can get shoes, food, clothing and free health screenings, among other things. Forming liaisons with local churches and government agencies can help hospitals address on-going problems, says LaRose.

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