Homelessness: A Health Crisis

Written by Diana Halloran, MD

Editor: Payal Modi, MD

You are working an overnight shift in the dead of winter. It is snowing outside, and the streets are empty. A call from EMS comes in: it’s a cardiac arrest.  You get ready to greet the ambulance and prepare for the resuscitation; you call your junior resident to assist and get your equipment ready: intubation supplies, face shields, the LUCAS CPR device, and central line kits.  As the patient rolls in on the stretcher and EMS starts giving their report, your heart sinks.  The patient was found by a friend, cold, unresponsive, and buried under blankets in his tent– he was homeless after all.  Your frantically attempt to rewarm him while continuing CPR but despite all attempts at resuscitation, you are unsuccessful and pronounce him dead. Cause of death: hypothermic exposure. The patient was exposed to the freezing winter temperatures for too long. 

As a second-year resident, I have seen this scenario one too many times in our emergency department. Homelessness is a public health crisis. Homeless patients come in for multiple reasons: environmental exposures (hypothermia, heat stroke), medication refills, traumatic injuries, and a lack of primary care access. I’ve seen homeless patients presenting to the emergency department with a heart failure exacerbation after not taking their diuretics because they did not have reliable and constant access to accessible restrooms. We have all seen patients with similar stories in emergency departments nationwide.  

Population Statistics

In 2019, an estimated 568,000 people nationwide were experiencing homelessness with about 37% of homeless individuals staying in unsheltered locations.  Furthermore, homelessness disproportionately affects people of color.  Almost 40% of homeless individuals are Black and 22% are Hispanic or Latino, despite representing 13% and 18% of the national population respectively. Comparatively, only 48% of homeless individuals are white, although they represent 77% of the United States population.

Homeless patients have a higher risk of substance abuse and mental health conditions. In a large retrospective study, 30% of homeless patient visits received a psychiatric diagnosis – six times higher than those of non-homeless patients. Homeless patients were diagnosed with non-dependent drug use at a rate eight times higher during emergency department visits versus non-homeless patients.

Emergency Department Utilization

A systematic review from 2015 identified chronic homelessness as a major barrier to primary care access and homeless patients have been found to have less access to essential preventative healthcare. When patients lack a medical home, the emergency department becomes the only dependable option for healthcare access. Emergency departments are legally obligated to stabilize and treat all patients regardless of insurance status or ability to pay because of the Emergency Medical Treatment and Labor Act (EMTALA). A federal law passed in 1986, EMTALA has guaranteed healthcare access for the most vulnerable in our society by preventing the transfer of uninsured or Medicaid patients to public hospitals without a medical screening exam.

As it currently stands the emergency department is the most reliable form of healthcare access for homeless individuals. The CDC estimated that from 2015-2018, there were 203 emergency department visits per 100 homeless individuals, as compared to 42 visits per 100 non-homeless individuals. Similar data can be found worldwide - a study in Canada estimated that homeless patients had visited the emergency department at a rate 8.5 times higher than the general population. 

Bias 

While the data above is critical, it is important as emergency physicians to watch for bias within our practice. Healthcare workers, including physicians, may have preconceived notions about patients with frequent ED visits. For example, a 2012 study on attitudes towards homeless people found that emergency department physicians had more negative beliefs compared to medical students. Although the underlying etiology is unclear, this belief can lead to bias and worse care in clinical practice. When homeless patients were asked to evaluate their healthcare experiences, most patients perceived their past experiences of unwelcomeness as acts of discrimination towards their low social class and homelessness. Many reported that this caused them to not want to seek healthcare in the future. This reflects an area of improvement for emergency physicians. 

Further Action

Policy changes at the local and national level continue to be a huge area for improvement. Last year the CARES act was passed by the House of Representatives which included $4 billion in emergency service grants for funding and protections for homeless Americans. In addition, the bill included $150 billion in COVID relief dollars which could be applied to housing needs. 

Additional action items to help those experiencing homelessness during the COVID pandemic includes recommending that patients get a COVID vaccine, offering diagnostic testing if indicated, continuing to work with social services to provide information about housing, substance abuse treatment, and providing Narcan kits when appropriate. It is important for physicians to be familiar with local social programs such as food pantries and food distribution sites in order to provide this information to patients.  

The COVID pandemic has changes the face of homelessness advocacy as well. During the CDC released interim guidance on homelessness, suggesting that people be given individual housing units versus communal shelters where COVID might be more easily transmitted. As we continue to follow vaccination levels in populations nationwide, these guidelines, if followed, could result in a decreased presentation of non-vaccinated homeless individuals with COVID in the emergency department.  

Homelessness is a public health crisis and as emergency physicians we have a legal and ethical responsibility to serve the homeless population. It is our personal responsibility to evaluate our own unconscious biases towards the homeless population to ensure they receive the same quality care we provide to non-homeless patients. Due to the high risk of substance use and psychiatric related issues among the homeless patient population, emergency departments might require additional social workers and psychiatric collaboration than currently utilized. Further policy changes are required to help support our homeless patient population, but in the meantime we should provide the support we can, whether it be medical interventions, social work utilization, food, or brief shelter.