Homelessness and hospitals
Hospitals and hospitalists are taking a harder look at their care for patients experiencing homelessness.
Optimizing medical care for patients experiencing homelessness starts with having at least a little familiarity with that experience, which many clinicians do not.
“When I do educational sessions for our trainees, I'm always struck by the large majority who have never set foot inside a homeless shelter,” said Stephen Hwang, MD, FACP, professor of medicine at the University of Toronto and director of the MAP Centre for Urban Health Solutions at St. Michael's Hospital in Toronto, Canada.
Limited knowledge about these facilities, and other aspects of being homeless, can negatively affect outcomes important to both patients and hospitalists. Erin Bredenberg, MD, MPH, offered an example of typical situations before the University of Colorado in Aurora, where she works, started tackling this issue.
“We were sending people places that really were not appropriate. We would discharge somebody that's wheelchair-bound to a place that doesn't have any wheelchair access, and they'd come right back to us,” said Dr. Bredenberg, a hospitalist and assistant professor of medicine.
Her hospital is not alone in recently launching a program, led by social workers and described in the Journal of Hospital Medicine in June, to try to avoid such errors and work harder to fill gaps in care for homeless patients.
“Hospitals across Canada and the U.S. are certainly becoming much more aware of the increasing number of people experiencing homelessness that they're seeing and the challenges that poses to providing high-quality care and postdischarge care,” said Dr. Hwang, who is studying the effects of navigators for patients experiencing homelessness.
Improvements in hospital care for this vulnerable population can be made on all levels, from the individual clinician's approach to systemwide interventions, experts said.
Starts with screening
“The first thing that we can do as clinicians is know patients' housing status. We don't do that routinely everywhere,” said David Velasquez, MD, MBA, MPP, a first-year medicine resident at Brigham and Women's Hospital in Boston who has written about care for patients experiencing homelessness.
Far from it, agreed Dr. Hwang, who has recently quantified that problem. “In the course of our research study, we have recruited hundreds of people that we know for sure are homeless, based on our careful screening and interviewing. Only about 60% of them were identified as homeless based on the diagnostic coding that was done at discharge,” he said.
One way to increase awareness of inpatients' housing status is to inquire on every admission. “Rather than asking people ‘Are you homeless or not?’ based on how they look, asking all of our patients, ‘Where are you staying?’ and ‘What's your housing situation?’ is a nonstigmatizing way of getting into that,” said Dr. Hwang.
Such questions can also better capture the variety of housing issues that may affect patients' health, according to Craig Pollack, MD, MHS, a professor of medicine and health policy and management who focuses on housing and health at Johns Hopkins University in Baltimore.
“There's really a housing crisis in the United States with a record number of individuals and households paying sky-high housing prices,” he said. “Things like eviction, foreclosure, loss of stable housing have really important implications for people's health and well-being, for their ability to be discharged effectively, for their ability to take medications.”
Another hospital staffer can question patients on this topic, as long as physicians are aware of the answers, the experts said.
“It doesn't have to be the clinician who asks and collects all the information around housing status for a person. It can be someone else on the team, like a social worker, who is more equipped and experienced with having these conversations,” said Dr. Velasquez. “But the team should know. Knowing is the first component of doing something about a person's housing status.”
What to do
The actions taken during hospitalization to respond to a patient's housing status don't have to be huge to make a difference, according to Dr. Bredenberg. “Recognize we're meeting people where they are and we're not going to be able to solve their housing situation in an acute care hospitalization,” she said.
Discharge planning and instructions are aspects of care where homelessness is an important consideration. “It's pretty simple stuff, but we just have to be aware of things that we take for granted when we discharge patients,” said Dr. Hwang. “There's a very high risk that what can go wrong will go wrong.”
He offered examples from diabetes and wound care. “Is there a place where they can refrigerate their insulin? … If we tell the patient that wound care is going to be an important part of their aftercare, are we ensuring that there is actually a place that they can reliably get to?” Another example is that diuretics can be problematic for patients without regular bathroom access.
The quantities of any prescriptions dispensed at discharge might need to be based on patients' ability to safely store medication or access refills. Extreme weather should also be a consideration in prescribing, added Dr. Velasquez.
“When a person is out on the street in the heat, does the person's body temperature affect the kinetics of a particular drug? Might that person be at increased risk of not having a steady dose? Does that mean they might be at higher risk of complications?” he asked.
Dr. Hwang summarized the overall concept. “Bolster the discharge plan,” he recommended, adding that hospitalists shouldn't have to do this alone. “Having specialist experts who can help the physicians is really important.”
At his hospital, that currently takes the form of the trial navigators, who are case managers employed by the hospital to work with patients during hospitalization and for 90 days after. They help patients follow their postdischarge plans and connect them with community-based health and social services.
Similarly, the Colorado program involves social workers and a nurse case manager working with community organizations to connect high-risk homeless patients with available resources after discharge.
“When you're just an individual hospitalist working the floor, especially if you're not familiar with what's out there, there's probably more than most of us appreciate,” said Dr. Bredenberg. “We tend to see folks who are coming in over and over and aren't well connected with resources, but if you can just get people plugged in with one of these community places, a lot of times, there's so much they could do.”
This is also true for patients with unstable, rather than no, housing, Dr. Pollack noted. “There are a lot of other interventions, for example, helping people get legal representation when they're facing eviction,” he said. “Or helping patients connect with resources that give them access to short-term rental assistance. More work is needed so that these interventions are more widely available. “
Some hospitals have developed homelessness consult teams to provide expertise for such situations. “It's not common practice across U.S. hospitals, but there are many examples,” said Dr. Velasquez. “Clinicians and health care staff more generally can try to champion a program that installs a housing specialist within hospitals or at least affiliated with a hospital.”
Postdischarge respite facilities are another amenity that hospitalists can push for, Dr. Hwang suggested.
If your hospital lacks such specific resources, don't despair, but do look around. “One of the most important things is to try to understand what community resources are available, in particular, working with community health workers or social workers,” said Dr. Pollack.
He noted that his outpatient primary care clinic has begun referring patients to community health workers. “Talking to my patients who've been referred to the community health worker, they've been really very satisfied and feel like this is a really wonderful and important role for their physician and health care team.”
Similarly, Dr. Bredenberg's study found positive responses from the patients treated under the intervention, as well as from the program's staff and those they interacted with to help meet the patients' needs.
“Our community partners were happier because they're getting more appropriate referrals. Other social workers who work on the inpatient side are happier,” she said. “The basic idea of giving the social workers the flexibility to go outside of the hospital walls and the time and space to become experts in their field is really powerful.”
Money and experience
Of course, hospital administrators often fund these programs hoping they will have power over other outcomes, specifically, those that affect hospital finances.
“The hope is that some of these efforts will lead to reductions in hospitalizations, reductions in ED visits, which could decrease health care spending, but that's a very high bar for a lot of these programs,” said Dr. Pollack. “It's going to be important for us to recognize that a lot of these interventions may not save money for a health care system but can still be really beneficial.”
“It's really difficult to see a measurable impact on readmissions,” agreed Dr. Bredenberg, who noted that the Colorado program, launched in 2021, has just recently collected its first data suggesting possible cost-effectiveness.
For these reasons, Dr. Hwang's study focused on some other outcomes. “Our primary outcome is whether or not the patient sees their primary care provider within 14 days of discharge, as that's a quality indicator and also a process indicator linked to reduced risk of readmission. We're also looking at patient experience outcomes,” he said.
Patient experience should also be a consideration for hospitalists trying to improve care for those without housing, the experts agreed.
“There's a high risk that patients experiencing homelessness have had negative experiences with the health care system. Just understanding that and preparing ourselves as physicians to work with these patients in a way that doesn't create those feelings is important,” said Dr. Hwang.
Dr. Velasquez offered some advice on how to do so. “This is a person who we should treat like everyone else who is coming into our hospital. We should sit down with them, listen to their story. Homelessness does not define them,” he said. “This isn't going to permanently be part of your one-liner when I think of you, but rather a component of your social situation.”
Thinking about homelessness as a modifiable risk factor in patients' lives can significantly shift one's approach to their care, Dr. Velasquez added.
These are the kind of lessons that need to be more common in medical training, according to Dr. Hwang.
“Having an understanding of the causes of homelessness and the challenges people experiencing homelessness face, understanding the trauma and the adversity that they've experienced, and having just a basic understanding of the daily life of someone experiencing homelessness is really important, and so education and support for physicians to be able to do that better is really important, especially in hospitals where a significant number of patients are experiencing homelessness,” he said.
The good news is that such education is often not hard to get, especially if street medicine is practiced anywhere nearby.
“There are doctors who work in the community who know the homeless situation in that community really well,” Dr. Hwang said. “Hospitalists are not always aware of those resources and are not taking advantage of the fact that there are physicians and other health care experts who could come to the hospital and help them understand the system and how they can serve their patients better.”