COMMITTEE REPORT
SOCIAL EM AND POPULATION HEALTH
Housing is Health Care: How the COVID-19 Pandemic Could Change the Way We Address Homelessness in the ED Victor Cisneros, MD MPH, Shashank Somasundaram, BS, and Sara Urquhart, MA RN
It is believed that 20% of the estimated 550,000 unhomed individuals in the U.S. are children who are dependent on public resources such as school lunches and public libraries. With pandemic restrictions, many children experienced hunger and were unable to keep up with virtual school plans.
E
ven before the COVID-19 pandemic, emergency physicians served as de facto primary care providers and safety nets for people experiencing homelessness. The COVID-19 pandemic has highlighted the glaring need for innovation in emergency care and a structured approach to mitigate homelessness.
Medico-social Safety Net Emergency departments (EDs) have long served as our nation’s health safety net for vulnerable populations. Recent data showed that from 2015-2018, annual average ED visits were 203 per 100 homeless persons compared to 42 per 100 among the general population. Amidst the economic downturn caused by the COVID-19 pandemic, the permanent closure of many businesses caused an estimated 45% surge in the number of unhomed people in the U.S. A report in 2020 in the U.S. found that 400,000 new shelter beds were needed in addition to the 291,837 existing temporary shelter beds with an estimated annual cost of $11.5 billion to adequately meet the needs of the growing number of people experiencing homelessness. Many people experiencing homelessness are unable to access or maintain a consistent primary care provider and rely heavily on the ED for social resources and management of chronic medical conditions, such as diabetes, hypertension, end-stage renal disease, and HIV. For ED physicians, it is often challenging to facilitate safe discharge from the ED, leading to a lower threshold for hospitalization and longer ED stays, further increasing the health care burden of homelessness. Though the complex medico-social needs and dearth of clinical care guidelines make this a challenging population to serve, research shows that ED screening and intervention could reduce ED visits and improve housing stability.
Impact of the COVID-19 Pandemic During times of public health emergency, the unhomed are some of the most physically, socially, and medically vulnerable populations. The structural housing deficits along racial and socioeconomic lines predispose marginalized communities to suffer most. During the pandemic, the inability to shelter in place or self-isolate put homeless people at high risk for contracting and transmitting the virus. This population’s skew towards older adults and propensity for medical and psychiatric comorbidities put them at further risk for severe disease and higher mortality. 26
COMMON SENSE SEPTEMBER/OCTOBER 2021
Public health measures such as social distancing, business closures, and shelter-in-place orders severely limited access to critical social and medical resources and services as well. This disruption in access to care was worse for homeless individuals, who rely on spaces like restaurants and libraries for food and hygiene. This left them largely unable to follow public health recommendations such as surface disinfection and regular handwashing. With social distancing requiring a reduction in bed volume at shelters and hospitals, these facilities were largely unable to meet the rapidly growing needs of their communities.
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EMERGENCY DEPARTMENTS HAVE LONG SERVED AS OUR NATION’S HEALTH SAFETY NET FOR VULNERABLE POPULATIONS.
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