Housing and Homelessness
Written by: Corey Hazekamp, MS4 (University of Illinois College of Medicine)
What does it mean to be homeless? If someone calls their car home, are they homeless? Is someone sleeping on a friend’s couch “just for a while” considered homeless? A document produced by the U.S. Interagency Council On Homelessness begins by stating “homelessness is defined in a number of different ways.”(1) The U.S. Department of Housing and Urban Development (HUD) and U.S. Department of Health and Human Services (HHS) each have their own definition of homelessness.(2,3) HUD provides a concise definition of homeless: “a person who lacks a fixed, regular, and adequate nighttime residence.”(3)
The U.S. had an estimated 568,000 homeless people on any given night in 2019, about one-third of which were unsheltered in streets, cars, buildings or “in other places not suitable for human habitation.”(3) Of this alarming number, 35,000 were under the age of 25 experiencing homelessness individually.3 Furthermore, nationwide homelessness increased by 3% or 14,885 people between 2018 and 2019; mostly driven by a 16% increase in California.3 These are important questions and data for Emergency Medicine (EM) physicians to consider because our homeless population utilizes the emergency department (ED) at higher rates than those who are not homeless.(4,5) Homelessness is considered a risk factor for ED utilization, is associated with increased readmissions, and by some is considered “one of the most deadly conditions we see in the ED.”(6,7)
To better serve our homeless populations we need to be able to identify who they are, understand what contributed to their homelessness and further elucidate how EM can generate solutions. There are obvious and subtle barriers to identifying homeless patients. To date, estimating the prevalence of homelessness has relied on patient’s self-reporting homelessness.4,8 The obvious barrier to identifying homeless patients via electronic medical records is that homeless patients may list the address of friends, shelters or fictitious homes.(4) This leads to studies under reporting the prevalence of homeless patients treated in the ED. The National Hospital Ambulatory Care Surveys (NHAMCS) only reports .4%-.6% of patient’s residences listed as homeless whereas a recent study directly measured the prevalence of homeless patients and found the prevalence of homelessness among ED patients to be closer to 10%.(4) A more subtle barrier to identifying our homeless patient is using visual cues to identify if a patient is experiencing homelessness.(9)
A review looking at the material needs of ED patients concurred that the NHAMCS studies underreported homelessness in the ED with local studies reporting 2.5-6% of their ED patients experiencing homelessness. These figures rose significantly to 22.8% among high-risk alcohol and drug users and 22.3% for patients with a psychiatric diagnosis in Arizona. Furthermore it was found that 18.1% to 43.8% of patients reside in ‘unstable housing situations.’(10) In a Canadian study, vulnerable housing was measured as the number of residential moves from 2009 to 2013 and found that the more residential moves patients experienced the higher the association with acute care utilization, unmet healthcare needs and substance use.(11) These results highlight the idea that even before patients experience literal homelessness they may start to experience issues with health when their housing status is ‘unstable’. A qualitative analysis further corroborated this concept finding that patients tend to experience homelessness rapidly and unexpectedly.(12)
In 2018 a systematic literature review of homelessness and emergency medicine was published followed by a thought provoking commentary providing the groundwork for how EM physician researchers should focus their efforts to better serve our homeless patients.(5,7) The primary findings were that we are under recognizing homelessness and not meeting the distinct needs of homeless patients.(5) Improving our ability to identify patients experiencing homelessness will enable better treatment and future research.(7) What have we learned since?
Doran et al. 2019 found that precipitators of homelessness commonly fell into four categories: 1) social and health contributors, 2) personal agency versus larger structural forces (such as high rent prices or lack of employment), 3) lack of support from family or friends and/or, and 4) homelessness not being expected. High rent prices was a common contributor and more than half of participants attributed job loss as a reason for homelessness. Up to 2/3rds of respondents had previous episodes of homelessness and still reported the current episode unexpected. Most participants had not sought formal aid services to help because they either did not expect to be homeless or did not know about such services.(12) As EDs serve as safety nets for our communities, these results further emphasize the point that EDs are ideally positioned to identify not only who is currently homeless but who is at risk for becoming homeless. This year a prospective analysis of homelessness in patients after ED visits found that 5% of patients not literally homeless at their ED visit became homeless within 12 months, most of which occurred within 30 days following their ED visit. It was common for these patients to have had four or more ED visits within the past year and had also experience homelessness in the past.(13) These findings suggest that a conspicuous amount of patients were experiencing housing instability during their ED visit.
So how do we utilize these findings to improve as a society? Recent research has highlighted several areas of improvement to help EM physician’s better care for our homeless patients: 1) EM has no unified definition of homelessness, 2) we have no validated ED screening tool for homelessness and 3) there is a lack of formal resident training for treating homelessness.(4–7) We have to realize that our homeless patients for the most part are not just looking for a place to sleep or food. Literature has shown that patients experiencing homelessness have similar triage acuities and are sicker than patients who are not experiencing homelessness.(7) We already have ICD-10 codes for these problems: homelessness (Z59.0) and inadequate housing (Z59.1); we need to start using them. This will help improve our ability to accurately track homelessness incidence in the ED. Two studies found that EM residents rely on stereotypes to identify homeless patients and tend to deviate from the standard of care for homeless and feel tension about the boundary of ED social care.(9,14) We should consider integrating more homeless patient scenarios into our simulations to help with provider comfort in formulating feasible treatment plans.
To take it a step further we have to accept that improving healthcare for the homeless is only a temporary solution to a larger problem – unstable housing and homelessness. We need to start aligning with the healthcare shift from fee for service to value based care to help incentivize preventing homelessness. United Healthcare has started to invest into housing for patients and in some areas Medicaid is paying more for treating homeless patients. Lastly, EDs can partner with community and governmental agencies to help address the root cause of this. UI Health’s Better Health Through Housing in Chicago is a good example of such an initiative. I think it’s important to remember “homelessness kills, sometimes more slowly but just as reliably, as heart attacks or strokes” as so elegantly stated in a recent commentary.(15)
Editors: Lauren Walter, MD (University of Alabama at Birmingham), John Purakal, MD (Duke University)
1. Key Federal Terms and Definitions of Homelessness Among Youth.; 2018.
2. Frequently Asked Questions About Health Care for the Homeless. Nashville, TN; 2011.
3. The 2019 Annual Homeless Assessment Report (AHAR) to Congress. Washington D.C.; 2020.
4. Feldman BJ, Calogero CG, Elsayed KS, et al. Prevalence of homelessness in the emergency department setting. West J Emerg Med. 2017. doi:10.5811/westjem.2017.1.33054
5. Salhi BA, White MH, Pitts SR, Wright DW. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018. doi:10.1111/acem.13358
6. Amato S, Nobay F, Amato DP, Abar B, Adler D. Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization. Am J Emerg Med. 2019. doi:10.1016/j.ajem.2018.06.001
7. Doran KM, Raven MC. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018. doi:10.1111/acem.13392
8. Chambers C, Chiu S, Katic M, et al. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health. 2013. doi:10.2105/AJPH.2013.301397
9. Doran KM, Vashi AA, Platis S, et al. Navigating the boundaries of emergency department care: Addressing the medical and social needs of patients who are homeless. Am J Public Health. 2013. doi:10.2105/AJPH.2013.301540
10. Malecha PW, Williams JH, Kunzler NM, Goldfrank LR, Alter HJ, Doran KM. Material Needs of Emergency Department Patients: A Systematic Review. Acad Emerg Med. 2018. doi:10.1111/acem.13370
11. Harris M, Gadermann A, Norena M, et al. Residential moves and its association with substance use, healthcare needs, and acute care use among homeless and vulnerably housed persons in Canada. Int J Public Health. 2019. doi:10.1007/s00038-018-1167-6
12. Doran KM, Ran Z, Castelblanco D, Shelley D, Padgett DK. “It Wasn’t Just One Thing”: A Qualitative Study of Newly Homeless Emergency Department Patients. Acad Emerg Med. 2019. doi:10.1111/acem.13677
13. Doran KM, Johns E, Schretzman M, et al. Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis. Ann Emerg Med. 2020. doi:10.1016/j.annemergmed.2020.03.006
14. Doran KM, Curry LA, Vashi AA, et al. “rewarding and challenging at the same time”: Emergency medicine residents’ experiences caring for patients who are homeless. In: Academic Emergency Medicine. ; 2014. doi:10.1111/acem.12388
15. Doran KM. Commentary: How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019. doi:10.1016/j.annemergmed.2019.08.442