In the U.S., a homeless person's lifespan is 25 years less than average. In this episode, hosts Dr. Ayesha Khan & Dr. Quincy Moore explore how the EM providers can be pivotal in improving health outcomes for those that lack basic shelter with Dr. Kelly Doran and Stephen Brown.
Objectives:
1. Describe how housing and homelessness affect a person's health and health outcomes
2. Describe why emergency physicians should be addressing housing and homelessness
3. Define important terms relevant to housing and homelessness: transient, intermittent, and chronic
4. Highlight strategies for eliciting key information from patients
5. Discuss how best to process and address a patient's housing status in the ED
Additional Resources:
Housing and Health: An Overview of Literature
https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full/ https://www.rwjf.org/en/library/research/2011/05/housing-and-health.html
Medical Respites
https://nhchc.org/clinical-practice/medical-respite-care/
How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine
https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0196064419311266
Uptodate: Healthcare of Homeless Persons in the United States
https://www.uptodate.com/contents/health-care-of-homeless-persons-in-the-united-states?search=homelessness&source=search_result&selectedTitle=1~102&usage_type=default&display_rank=1
Take-home points:
1. There are 3 definitions within the category of homelessness.
- Transitionally homeless: 80% of homeless individuals in the U.S. Often times these are people who have fallen off the grid maybe due a financial catastrophe and they're mostly back into housing within 3 months.
- Episodic homelessness: People that are in and out of housing, couch surfing, or intermittently employed. Many of the people that age out of foster care belong to this group. There's less known about this population. Often, they also have a subacute mental illness that make it difficult to get the care they need.
- Chronic homelessness: 10% of the overall homeless population, tend to have high comorbidity with psychiatric illness and substance abuse. They're usually older and they're continually homeless over one year or homeless 4 times in the past 3 years. These tend to be the ones that are most easily identifiable in the ED.
2. With just 10% of homelessness being chronically homeless, we need to do a better job routinely asking people about their housing status. Possible questions to identify homelessness in your history include:
- "Where have you been staying at these days?"
- Ask a follow-up question like "Is that an apartment? Someone else's house? A shelter?"
3. When dispositioning your patient, consider the treatment plan and if the patient is in a place they can follow it. Even shelters do not provide 24hour sheltering. Consider medical respite or admission if needed.
4. Half of homelessness is in urban areas, 25% in suburban areas, and 18% in rural areas.
5. Ideally when we think about homelessness, we're trying to address the tri-morbidity of homelessness, substance use, and psychiatric illness.
6. Don't forget, help your patient get undressed and do a physical exam. It can be dangerous to avoid doing this.
7. This is a difficult population to work with and no one has all the answers including both of our experts, but it's important to recognize how challenging this is and support our especially young providers in trying to treat these patients even when you don't have a ton of resources. Try to make a difference in policies locally and nationally or even within your hospital to both help the problem and help a little bit with your tolerance of day-to-day frustrations. Connect to partners in the community or the Public Health Department to find collaborators. Emergency physicians really are the experts in homelessness and we can make a big difference in people's lives.
Contributors:
Guests:
Dr. Kelly Doran is an emergency physician and faculty in the NYU School of Medicine Departments of Emergency Medicine and Population Health who studies how healthcare systems can better address homelessness and other social determinants of health. Her research on homelessness has been published extensively and she was previously an advisor to the New York State Department of Health on an innovative program to use Medicaid funds to support housing.
Stephen Brown is a MSW LCSW who is faculty and Director of Preventative Emergency Medicine at the University of Illinois at Chicago. After a career in business, he switched gears to work as a social worker in the ED and soon afterward, was promoted to build a program to provide care coordination for high-utilizers of the ED. He is now the program director for Better Health Through Housing which transitions patients that are chronically homeless into permanent supportive housing. His work on this project has been featured in the Chicago Tribune.
