When the Prescription is Not a Medicine but a Home

For the first time since 2010, the rate of homelessness in the United States has increased—over 550,000 people were without stable housing at some point last year. Just as 2017 came to a close, many major cities held ceremonies for the now annual Homeless Persons’ Memorial Day, created to honor those who lost their lives in the streets over the year. If it doesn’t infuriate you that people in our country die this way—some of them right near the best hospitals in the world—it should. As a physician working at one of these hospitals, I am certain that we as a health system can do better for our homeless population.

I recall one especially cold morning as I walked into the emergency department ready for my shift to begin. I would unknowingly pass by my first patient of the day—a man sound asleep on the stretcher, snoring deeply. As I quickly scanned over his chart, I read that the patient, Mr. L, was found wandering around the field of a local college campus, disoriented and confused. To many physicians, Mr. L’s clinical history would be work enough: bipolar disorder; polysubstance abuse, including cocaine, prescription medications, and alcohol; a history of heart failure; and a diagnosis of blood clots in his lower legs. But his biggest medical problem of all— homelessness—was hardly listed as such in his clinical notes.

Unsurprisingly, the healthcare needs of the homeless are immense. In a study of homeless adults across the nation, the range of deficiencies included an inability to obtain needed medical and surgical care, prescription medications, mental healthcare, dental care, and eyeglasses. Ask any practicing physician that has cared for homeless populations and you’ll be assured the list goes on. In Mr. L’s case, he could have suffered serious consequences had police not found him when they did. Medical problems related to cold temperatures alone, including hypothermia and frostbite, are significant considerations for those without shelter. But his homelessness also reinforced his underlying medical problems, worsening his substance abuse, mental illness, and his inability to control factors that would worsen his heart failure, such as his diet.

After several minutes of trying to awaken him, I asked more loudly, “Mr. L! I need you to try and wake up or we will have to do further tests to see if you are okay.” He slowly opened his eyes, a thick, sputum-filled cough launching my way, and said, “I came here for my breakfast! Where is it?” Minutes later, he eloped from the hospital. For Mr. L, the emergency department was hardly a place he went expecting to receive medicines-- he presented with normal vital signs and (surprisingly) no acute medical complaints. I realized that for him, it was a way to receive a warm roof overhead and potentially a meal for the night. As his physician, I could hardly fault him. The warmth alone may have saved his life. And in many ways, he had pointed out a much larger problem with our healthcare system as it related to the care of the homeless.

Mr. L is not alone. According to Dr. Christian Arbelaez, an emergency medicine physician at Brigham and Women’s Hospital, emergency department usage among the homeless seems to be increased during the winter months, although this has yet to be formally proven in studies. “We often see a trifecta--a homeless man with polysubstance abuse and mental health needs who presents late in the night. The shelters are often closed and so we have nowhere to send these patients. We’ll often let them stay in the emergency department until the morning.”

While many of the homeless patients I have treated share a similar profile as Mr. L, the reality is that homelessness exists on a wide spectrum. As of July 2017, over 3,500 homeless families were in the Massachusetts’ Emergency Assistance (EA) shelter program. There are a number of temporarily homeless individuals who are not chronically homeless, but rather shift in and out of having stable housing because of financial hardship or other causes. Furthermore, nearly one in four homeless individuals is a veteran.

Emergency department usage is disproportionately high among homeless individuals compared to the general population. Factors that have been implicated in high rates of ED usage among the homeless include everything from food insecurity to mental illness. And the effects of homelessness are independently predictive of high ED usage regardless of insurance status. In a study of Medicaid patients, those who were homeless still had frequent ED visits and hospitalizations from these visits. In those who are homeless, mental illness more so than drug abuse is associated with emergency department use, as is Hepatitis C more so than HIV. Those with mental illness are also more likely to have a re-visit to an ED within 30 days.

As a civilian, I often see homeless people on the streets of Boston, holding out paper cups or cardboard signs with the hopes of collecting spare change. But as a physician, I am much closer to their hidden stories-- those of a life without support, safety, healthcare, or a blanket on a cold winter night, mostly due to circumstances out of their control. As a doctor, I can assert that homelessness in itself is a serious predictor of ill health on many levels with ample studies to support this. The lack of stable housing should be viewed not as an extra detail in the social history, but as a primary medical problem.

Unfortunately, many homeless individuals are still sent out of emergency rooms, or elope as Mr. L did, without any change to their housing status. For these patients, the emergency room can easily become another pit stop, rather than a place of potential empowerment. This is an opportunity we are missing as doctors—and our health system is failing us when our default option is sending these patients back to the street. Experts suggest that shelters are far safer for homeless individuals compared to the street in terms of mortality and morbidity related to complex psychiatric, substance abuse, and medical conditions with new data soon to be publicly released.

While some argue against homelessness being a responsibility of the healthcare sector, we know from key studies that the more we spend on social services, the better our healthcare outcomes, and the lower our healthcare costs. The Veteran’s Affairs administration has been especially proactive on this front, connecting homeless veterans who present to VA hospitals with social support and resources for stable housing. And some hospitals have started to follow suit: last month, Boston Medical Center announced a new $6.5 million housing initiative, the largest of its kind in Massachusetts by a hospital. Efforts to connect homeless patients in emergency departments with homeless shelters, job opportunities, and empowerment programs would provide an important gateway for these people to be more readily directed to the real medicine they need-- a way out of homelessness. It is a win-win opportunity that we should be hesitant to miss.

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