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Definition of Homelessness: An individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., a shelter) that provides temporary living accommodations, and an individual who is a resident in transitional housing -The U.S. Department of Health and Human Services (HHS) 3

o   Homelessness is a crucial social determinant of health and has a profound impact on an individual’s ability to perpetuate health, access to quality treatment, and to recover from illness.
o   The federal government reports about 1.5 million people a year experience homelessness,6 and on any given night in the U.S, over 500,000 people are homeless.1,7
o Etiology of Homelessness: a result of complex and multifactorial circumstances. Just to name a few variables related to the cause and perpetuation of homelessness include: increased urbanization, lack of low-cost housing, poverty, lack of support, failed government policy, health disparities, psychiatric illness, gaps in the social safety net, domestic violence substance use and addiction.3,8,

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o   Homeless individuals have higher rates of illness and mortality, and die on average 12 years sooner than the general U.S population. 9,11

o   The numerous health conditions observed among the homeless population are commonly a combination of significant physical, social, psychological, and substance use related problems.9

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Emergency Department (ED) Utilization by the Homeless Population 

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Emergency Department (ED) Utilization by the Homeless Population 

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o   The ED serves as the only accessible source of universal health care in the United States, homeless people have been shown to have significantly higher rates of ED utilization when compared to the general population.1,21,2,3,7,16
o In a study of 2578 homeless persons looking at high repetitive use rates, it found the homeless individuals who frequented the EDs more often had less stable housing, victimization, arrests, physical and mental illness, and substance abuse.15
o A study examining 30-day ED revisits among homeless patients with mental health conditions found that among patients with mental health conditions, being homeless contributed to an additional 28% increase in likelihood of 30 day ED revisits and 38.2% increase in likelihood of hospital readmission,

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1.) Improved Screening
o   Prevalence of homelessness in the ED is primarily estimated from the ED component of the NHAMCS database which provides a nationally representative survey of U.S ED visits, this has been shown to significantly underestimate homelessness due to measurement limitations, citing that people who are homeless account for around 0.5% of ED visits nationally, where studies in individual EDs using more robust measurements found much higher rates.21
o   “Homelessness” is an ICD-10 code, though this question is rarely routinely asked by providers.

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2.) Increased Emergency Department Practitioner Training
o   Most emergency medicine residency programs have no formal curriculum related to homelessness, despite this being a core population in the ED. 33
o   One study of emergency medicine trainees found that they often rely on “visual pattern recognition” to identify which patients are homeless, which introduces bias and creates an unreliable way to recognize and document this population. 33

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Clinical Profile of Emergency Department Visits by Homeless Individuals with a Mental or Substance Use Disorder

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Clinical Profile of Emergency Department Visits by Homeless Individuals with a Mental or Substance Use Disorder

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4.)  Assertive Community Treatment Teams
o   The assertive community treatment model consists of wide-ranging multidisciplinary team who share the same patient case in order to provide a comprehensive range of direct services to patients.
o A study was conducted to evaluate the cost effectiveness of an assertive community treatment program (ACT) compared to usual care in homeless patients with severe mental illness. 23 It found that compared with usual care, ACT costs were significantly lower for mental health in-patient days and mental health emergency room care, and significantly higher for mental health out-patient visits and treatment for substance misuse. 23 ACT and usual services incurred $242 and $415 respectively in direct treatment costs per day of stable housing, an efficiency ratio of 0. 58 in favor of ACT.

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3.) Intensive Case Management Programs
o   Encompasses a range of service delivery practices such as assertive outreach, factoring in consumer need, and coordination of care; it is less intensive and standardized in comparison to the assertive community treatment model. 38

o   Interventions that have been suggested include implementing screening questions, brief and targeted intervention, referral to specific treatment programs and providing take-home naloxone to prevent opioid overdose.31 Despite these noble suggestions, currently in most EDs, if a patient request help for substance use, they are simply handed a list of resources and instructed to call on their own.
o Multicenter trial of health insurance outreach among uninsured children presenting to the ED, it found that by simply hanging out blank insurance applications could quadruple the odds of successful enrollment. If this was readily adopted across the US, it could lead to the coverage of more than a quarter million additional children a year.37

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5.) Supportive Housing
o   Studies consistently show that secure housing improves health and decreased ED utilization.2 However, housing is rarely considered a mode of health care delivery.
o   Partnerships between hospitals and homeless services have proven to be extremely effective in coordinating care.
Emergency medicine researchers worked with the Housing First partnership between the Centers for Medicare and Medicaid Services and New York City, which provided housing for high-risk homeless patients, resulting in improved health and cost savings for the city.31

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o   The emergency department (ED) has a unique opportunity to intervene and combat the underlying health and socioeconomic issues of homelessness in hopes to overall decrease the utilization of emergency services and increase the access to care and outpatient options.
o It is recommended that: providers ask standardized questions regarding a patients housing status, formal guidelines and educational training in providers curriculum to assist in managing homeless patients, dedicated social outreach and ACT will pay for themselves by decreasing amount of ED visits and admissions, and that integrated data sharing between the ED and housing outreach programs is effective at facilitating process of supportive housing (housing=health)

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Please see link below for full reference list.

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