Caring for Homeless Populations in the ED: A Quick Guide

Homelessness is defined as lacking a regular night-time residence, or having a primary night-time residence that is a temporary shelter or other place not designed for sleeping.¹

Approximately two-thirds of people experiencing homelessness are individuals, and one-third are members of families with children.² The emergency department plays a crucial role in health care for homeless populations, as it serves as the first — and often the only — resource for accessing health care in these populations.

People experiencing homelessness commonly present to the ED for health care needs. When a person newly experiences homelessness, they are nearly 25 percent more likely to present to an ED.³ In 2017, there were an estimated 990,000 ED visits by people experiencing homelessness.⁴ Additionally, increasing frequency in ED visits is associated with homelessness. From 2015 to 2018, the CDC reported about five times as many ED visits by persons experiencing homelessness compared to persons not experiencing homelessness.⁵

Interventions to address homelessness are vast and range from individual and local resources to systemic interventionand social change. According to Sadowski et al, permanent supportive housing is currently the best intervention to address frequent ED visits by individuals experiencing homelessness.⁶

Risk Factors/Clinical Outcomes
Homelessness is an important social determinant of health. Individuals experiencing homelessness are faced with many barriers to achieving health and wellness and frequently experience worse health outcomes than those not experiencing homelessness.

Homelessness is associated with a worse all-cause mortality,⁷ especially in those with STEMI, cardiac arrest, and stroke.⁸ Chronic diseases — including diabetes, hypertension, asthma, infectious disease (e.g., tuberculosis, HIV, hepatitis A, and hepatitis C), depression, and substance use disorders — are more common among those newly experiencing homelessness.^9,10 Additionally, homelessness is associated with an increased risk of premature death. The most common cause of death among patients experiencing homelessness is drug overdose (seven-fold increase compared to the general population⁷), followed by cancer and heart disease.¹¹

Patients experiencing homelessness may have difficulty storing and taking medications as prescribed due to their housing circumstances, and many report having medications stolen in shelters or on the streets.¹² Patients experiencing homelessness are more likely to present to the ED with burns and injuries to the lower extremities, and to have more severe injury patterns and longer injury-related hospitalizations than patients not experiencing homelessness.¹³ According to Fazel et al, 27–52 percent of people experiencing homelessness were physically or sexually assaulted in the previous year. Nearly 10 percent of homeless women reported a sexual assault in the previous year.¹⁴

Bedside Awareness
As emergency physicians, we are charged with caring for patients experiencing homelessness frequently throughout our careers, and it is imperative that we are well-informed and equipped to care for both their medical and social needs. Given the emergency physician’s unique opportunity to care for individuals experiencing homelessness, we have a responsibility to consider the barriers and challenges that individuals experiencing homelessness face during our care for these patients.

As emergency physicians, we can help reconcile health inequities at the bedside for individuals experiencing homelessness by:

• Treating all patients with the same level of respect and open-mindedness
• Routinely screening for homelessness. Ask all patients about their housing status as part of the social history. Many patients experiencing homelessness will not fit the stereotypical profile. Consider asking¹⁵:
  • Where do you live?
  • Where are you staying these days?
  • Have you ever had nowhere to stay for the night?
• Documenting homelessness in the social history, beyond mentioning it in a single note
• Not inserting “homelessness” as a chief complaint, as this may mask comorbid health conditions and introduce bias¹⁵
• Considering a history of homelessness and associated risk factors throughout the patient interview, in the context of the review of systems, and when performing a physical exam
• Allowing for a broad differential diagnosis that reflects the high morbidity and mortality burden faced by this population, including (but not limited to) issues such as cardiac disease, stroke, hypertension, diabetes, infectious diseases, mental health disorders, and substance use disorders

Key Actions
As emergency physicians, we can address these social/structural determinants of health by:

• Linking individuals experiencing homelessness to available community resources, as EDs represent a critical setting for encountering homelessness and assisting individuals in finding help^16,17
• Addressing immediate needs. Although some basic necessities, such as food and clothing, are not typically thought of as medical care, they are nevertheless critical to human survival and compassionate patient care.¹⁵
• Social Work:
  • Know your ED’s social workers, their hours of operation, and the different ways in which they can help. Engage social work early when necessary, especially for patients who utilize the ED often.
  • Know your community housing resources. Be ready to provide at least one referral source for shelter or housing assistance.
• Discharge:
  • Consider whether activity restrictions are needed. Most homeless shelters do not allow patients to rest inside during the day. Supportive care measures such as extremity elevation can be difficult in a shelter and impossible on the street.¹⁵
  • If you’re discharging a patient with a contagious infectious disease, consider how this will affect their eligibility to stay in a shelter. This is particularly relevant to the COVID-19 pandemic.
• Medication Prescriptions:
  • Consider medication cost and accessibility to outpatient pharmacies.
  • Patients may not have access to refrigeration, which is problematic for certain medications such as insulin.
  • Consider the complexity of medication dosing schedules, and opt for single-dose treatments when feasible (e.g., consider single-dose dexamethasone injection rather than steroid dose pack prescriptions for asthma).¹⁵

This article is part of an EMRA Social EM Committee initiative to disseminate information about social EM topics encountered in the emergency department. More information can be found in the EMRA MobilEM app’s Patient Conversation Toolkit, available for download via iTunes and Google Play.

References

1. Stewart B. McKinney Homeless Assistance Act of 1987, Pub. L. No. 100-77, 101 Stat. 482, (Jul. 22, 1987)
2. Henry M, Watt R, Rosenthal L, Shijvi A. The 2017 annual homeless assessment report to congress. Washington, DC: HUD Offce of Community Planning and Development; 2017.
3. O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Preferences for sites of care among urban homeless and housed poor adults. J Gen Intern Med. 1999;14(10):599–605. doi:10.1046/j.1525-1497.1999.09258.x
4. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics.
5. National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2015–2018. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.
6. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009;301(17):1771–8. https://doi.org/10.1001/
7. Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol 2009;38:877-83.
8. Wadhera RK, Khatana SAM, Choi E, et al. Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions. JAMA Intern Med 2020;180:357-66.
9. Schanzer B, Dominguez B, Shrout PE, Caton CLM. Homelessness, health status and health care access. Am J Public Health. 2007;97(3):464-9. doi: 10.2105/AJPH.2005.076190
10. D’Amore J, Hung O, Chiang W, Goldfrank L. The epidemiology of the homeless population and its impact on an urban emergency department. Acad Emerg Med. 2001;8(11):1051–5.
11. Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al. Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95
12. Coe AB, Moczygemba LR, Gatewood SB, Osborn RD, Matzke GR, Goode J-VR. Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic. Res Social Adm Pharm. 2015;11(3):e110–e20.
13. Mackelprang JL, Graves JM, Rivara FP. Homeless in America: injuries treated in US emergency departments, 2007–2011. Int J Inj Contr Saf Promot. 2014;21(3):289–97.
14. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529–40. https://doi.org/10.1016/s0140-6736(14)61132-6.
15. Salhi, B.A., Doran, K.M. (2021). Homelessness. In: Alter, H.J., Dalawari, P., Doran, K.M., Raven, M.C. (eds) Social Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-65672-0_14
16. Doran KM, Raven MC. Homelessness and emergency medicine: where do we go from here? Acad Emerg Med. 2018;25(5):598–600. https://doi.org/10.1111/acem.13392.
17. Salhi BA, White MH, Pitts SR, Wright DW. Homelessness and emergency medicine: furthering the conversation. Acad Emerg Med. 2018;25(5):5