The disproportionate use of emergency services by homeless people is no secret. (BMC Health Service. 2021; 21: 428; https://bit.ly/3EXx4k8.) Overuse not only strains the healthcare system, it is also a major source of burnout for PE. (Ann Emerg Med. 2019; 74[5S]: S19; https://bit.ly/3bYrxgB.)
Homelessness sometimes manifests itself as treatable medical problems, but the root cause of these problems is clearly structural deficits in society. The lack of a solution to looming structural problems leads physicians to spin the wheels, sending these patients to the streets and perpetuating a cycle of discharge and re-presentation.
Yet the solution is right in front of us. “Housing is health care” should be not just a mantra, but an evidence-based policy. Providing housing reduces emergency room visits and the use of EMS. (JAMA. 2009; 301: 1771; https://bit.ly/3klKLS8; Psychiatric service. 2006; 57: 992; https://bit.ly/30dVw1p; Prehospital emergency care. 2014; 18: 476; https://bit.ly/3wuIQ2v.) Housing solves many legitimate medical problems and reduces hospitalizations and length of stays. (BMC Health Service. 2011; 11: 270; https://bit.ly/3C0yLeE; J Urban Health. 2021; 98: 505; https://bit.ly/3CZWtcl; Am J Public health; 2006; 96: 1278; https://bit.ly/3wxgjZW.)
Housing First models show that housing, even in the absence of an abstinence requirement, significantly reduces alcohol use among alcoholics. (JAMA. 2009; 301: 1349; https://bit.ly/3F1fifS.) All of this, of course, equates to significant cost savings, even after factoring in the cost of housing. (BMC Health Service. 2011; 11: 270; https://bit.ly/3C0yLeE; Health Service. 2012; 47[1 Pt 2]: 523; https://bit.ly/3D4PsXV.)
Overwhelming evidence indicates that housing is part of health care, but many doctors do not view housing as their responsibility but as that of a social worker. The truth is, finding housing is not a task for a social worker or a doctor, but for both. I always appreciate when a social worker contacts me to voice concerns about an unsafe exit plan. Doctors can and should advocate for safe discharge plans as well.
Homeless shelters are insecure environments where medical supplies and prescriptions can be stolen, infectious diseases spread faster, and the stress of their transience prevents people from prioritizing their health care. (National public radio. 6 Dec. 2012; https://n.pr/3wBYGsg.) Discharge in these places may very well cause medical damage.
Find a home
Some homeless patients, such as those with permanent disabilities or mental illnesses, are clearly suitable for placement in skilled nursing facilities or personal care homes. Unfortunately, this often goes unrecognized until a patient exhibits growth retardation or another euphemism for the lack of necessary support. We should be more proactive in identifying patients who are unlikely to be taking care of themselves. Physical and occupational therapy assessments are a good start for physical disability, but maybe we should also be doing cognitive assessments more regularly.
If long-term placement is not appropriate for a patient, my next step in securing housing is to find out about a patient’s income sources, ask them about their salary, disability and social security. I will also ask him if it is family support or if it belongs to a church or other community. It helps me sort out the options that will be available and manage patient expectations. Many times a patient will have a combined income sufficient to afford low rent housing on their own and all they need is information on how to apply. The income can be used to negotiate a contract with a personal care home in other situations.
However, patients often lack substantial income. In these cases, it is helpful for the doctor to know about community programs for the homeless. Atlanta has a centralized intake center called Gateway that determines the best program based on the patient’s age, gender, co-morbidities, and other factors. Most of these programs require self-registration, but recognizing that many homeless people will go to the emergency department for help instead of Gateway, Hospital to Home was created so that hospitals could house the people. patients bypassing central admission.
Barriers and last resort
Some illnesses open up additional sources of funding that can be used for housing. People living with HIV can access housing through programs federally funded by the Ryan White Comprehensive AIDS Resources Emergency Act. More recently, people diagnosed with COVID-19 were eligible for hotels to facilitate isolation for public health reasons. Unfortunately, I have had patients who were visibly upset when their COVID-19 swab produced a negative result because it closed a housing opportunity.
These are examples of biological citizenship, when people have access to social protection programs based on a medical condition. (Oxford Bibliographies. April 23, 2021; https://bit.ly/3HdmQ0Q.) Biological citizenship is indicative of our society’s tendency to compensate for disease rather than prevent it. We will allocate funds to housing patients after contracting COVID-19 to protect others, but will also ask them to congregate in shelters, thus increasing their risk of contracting the coronavirus in the first place.
If I am unsuccessful in securing permanent accommodation for a patient, I investigate temporary accommodation such as medical respite or a 30 day contract with personal care homes. The obvious concern is that patients will be on the streets again after the period of acute illness or the end of the paid contract, but studies have shown that even temporary accommodation reduces hospital readmissions. (J Prev Interv Community. 2009; 37: 129; https://bit.ly/3HcvOM0.) Temporary housing should also be combined with outpatient case management to start the process of securing stable funding and permanent housing.
Fortunately, physicians are increasingly recognizing the role of structural violence and the social determinants of health in the cause of disease. Ultimately, roaming in one of the richest countries in the world is a political choice. As physicians, we can commit to seeing housing as part of patient treatment plans, but we should also use our power and privilege to advocate for greater structural change. Housing is health, and it should not only be proclaimed as an adage but also practiced on a daily basis.
Dr Kolepractices hospital medicine at Grady Memorial Hospital in Atlanta through Emory University. He is also an alumnus of the HEAL Initiative and focuses on health equity nationally and internationally..