Addressing Housing Insecurity in the ED: A Resident’s Perspective

Written by Jasmine Y. Gale, MD, and edited by Jacqueline Furbacher, MD, and Payal Modi, MD, MPH, on behalf of the SAEM Social Emergency Medicine and Population Health Interest Group

A Case

A disheveled 68-year-old male in no acute distress presented with chest pain. The EKG was nonischemic. The history was inconsistent. He interjected to ask for a sandwich because he hadn’t eaten in three days, and my concern for a medical emergency instantly decreased. I asked where he lived, and after asking three different ways, I finally learned he was sleeping on “the streets.”

I reviewed his chart and, as expected, found no recent emergency department (ED) visits. Instead, I discovered that he had an extensive cardiac history. The concern for a true medical emergency now rose back up on my differential, and he was appropriately worked up for his chest pain. The workup was negative, and he was medically cleared to be discharged home. Now what?

Transitions

As I make the transition from medical student to emergency medicine (EM) resident physician, competing demands have felt like they have skyrocketed, and with them, so have feelings of defeat, overwhelm, and helplessness. As a medical student, I would have easily spent an hour with this patient, hearing his story, discussing why he wasn’t taking his medications, and offering resources. While fourth year of medical school is about learning the medicine and maximizing patient care, intern year is about learning the medicine, balancing multiple active patients, and become efficient at doing so, without sacrificing patient care. Priorities shift to learning to think about disposition and department flow. The reality is that there is a waiting room of 30 patients, the orthopedic consult is finally on the phone for your patient next door, you still haven’t gotten around to repairing that facial laceration, and yet another patient is attempting to leave against medical advice. We are trained exceptionally well in how to approach chest pain, but we can flounder when it comes to addressing social determinants of health. How do we ensure that this patient gets the care he needs, without letting another patient fall through the cracks?

Background

On any given night in 2020, 580,000 individuals experience homelessness in the U.S., and this number has been increasing for four consecutive years. The most recent available statistic demonstrates that in 2017, ED prevalence of unhoused individuals or individuals at risk of being unhoused in the U.S. was 10.1%. It’s important to note that unhoused does not necessarily mean living on the street. Individuals without stable housing, such as those “couch surfing,” living in their car, or staying with friends or family also constitute homelessness, and most of these individuals are without stable housing only temporarily It’s easy to identify the disheveled patient with a shopping cart full of tattered bags as someone without stable housing, but anyone, regardless of how they appear, can be housing insecure. Patients experiencing housing insecurity utilize the ED at higher rates than the general population. They tend to be sicker than the general population and have more chronic conditions. Moreover, life expectancy of individuals experiencing homelessness is 25 years less than the general population. Some individuals without stable housing come to the ED for temporary solutions to social needs (e.g., a sandwich or warm bed) yet these can be some of the sickest patients in the ED due to their chronic illnesses, difficulty accessing preventative care, and exposure to environmental elements. In fact, it’s far more likely that patients with housing insecurity will continued on Page 52 continued from Page 51 avoid seeking medical care until the absolute last minute for a variety of reasons: competing priorities such as shelter and food, past mistreatment, mistrust, financial trouble, or lack of transportation. By the time these patients finally get to the ED, they are often acutely ill with advanced disease. While addressing social determinants of health in the ED is gaining traction, most emergency medicine residency programs have yet to implement a formal curriculum. After spending time in my community, I have observed some strategies — both on and off shift — for addressing housing security within the realistic time constraints.

Strategies for On-Shift

Ask about housing

Here is a simple, nonjudgmental question that takes only seconds to ask: “Where are you staying these days?” Learning and using this phrase allowed me to identify patients who were experiencing homelessness, even transiently. Asking every patient this same question limits potential stigma and bias and normalizes the importance of housing to health. While it’s unlikely to find the patient immediate stable housing, understanding housing has changed how I handle a patient’s discharge plan. Considering prescription cost, follow up, and management of chronic wounds are a few specific areas that I may adjust to better support a patient’s adherence.

Utilize interdisciplinary health care staff

Social workers are experts in community resourcing and are better equipped to match resources to an individual’s need with regard to shelter, substance use treatment, mental health counselling, food, insurance, and transportation. Furthermore, social workers may be able make calls to community resources to directly connect patients with an open shelter bed.

Barriers to medication adherence for unhoused individuals include cost, complicated instructions, dose frequency, and theft. Pharmacists are an additional asset in these situations, especially when a patient needs instruction on a specific medication such as using an inhaler. Pharmacists also often know the cheapest prescription option, which medication has the lowest dose frequency, and which has the simplest instructions. A strategy I learned to help prevent medication theft is to prescribe smaller quantities more frequently.

Medical students are another valuable resource toward better understanding of a patient’s story and specific needs. I know that as a student, I would have jumped at this opportunity!

Strategies for Off-Shift

Understanding primary care community resources for housing insecure patients

Familiarizing myself with community resources outside the clinical environment has changed how I practice and improved my ability to care for patients on shift. For example, mobile primary health care clinics provide consistent care access for housing insecure patients and seek to build therapeutic patient relationships outside the traditional clinic setting. Other organizations focus on addressing the trimorbidity of housing insecurity, substance use disorder, and mental health disorders with multidisciplinary care models. Each community resource is unique and learning what’s available in the local area may increase access to care and impact patients in real-time while on shift.

Recognize how to support patients in staying out of the hospital

Medical respite facilities provide temporary housing for individuals who are not sick enough to be admitted to the hospital but are too sick for a shelter. Many shelters require residents to leave during daytime hours, making following discharge instructions for wound care and rest particularly difficult and puts individuals at risk for wound infections and increasing morbidity and mortality. Medical respite facilities can help decrease these risks.

Maintain a supportive culture

Cultivating a supportive culture is paramount to wellness. Many of us choose emergency medicine because it’s the only specialty that treats anyone who walks through the door, anytime; however, when the same patients walk through that door repeatedly, it can be frustrating. Increased ED volumes and time pressures can exacerbate these feelings. Acknowledging feelings like these and creating spaces to debrief have been key in remembering my own humanity and that of my colleagues and, most importantly, my patients.

Conclusion

Homelessness and chronic conditions are connected in a vicious cycle — having a chronic illness can lead to homelessness, and homelessness can lead to being unable to care for the chronic illness. While these strategies, do not address the root causes to housing insecurity, they are practical tools to support residents both on and off shift. The ED is uniquely positioned to have access to individuals experiencing homelessness; this also means we, as EM physicians, are in the unique position of being able to do something about it — and that is exactly what we should be doing.

About The Authors And Editors

Dr. Gale is an emergency medicine resident at the University of Massachusetts in Worcester, MA. She completed medical school at Tufts University in Boston, MA.

Dr. Furbacher is a second-year emergency medicine health equity fellow at University of Massachusetts in Worcester, MA. She completed her emergency medicine residency at The Ohio State University and medical school at The University of Texas Health Science Center at Houston.

Dr. Modi is an assistant professor at University of Massachusetts Chan Medical School where she serves as the director of the health equity division and fellowship. Dr. Modi is the co-chair of the SAEM Social Emergency Medicine and Population health Interest Group.