Special Considerations for Homeless Patients in the Emergency Department

The emergency department is often the first place that a homeless patient steps into to seek medical aid, and as such, the special considerations in the care of this particularly vulnerable patient population is an important discussion for aspiring emergency medicine physicians.

In 2017, a YaleGlobal article estimated that there were approximately 1.5 million homeless people worldwide, which made up 2% of the global population at the time. In the same report, they noted that an estimated 1.6 billion people lacked “adequate housing,” which unfortunately has no specific definition and thus varies from country to country, as well as from study to study.¹

Nevertheless, it is apparent that the numbers are staggering. For an in-depth overview of the statistics relating to homeless on a global scale, Wikipedia offers a list of countries by homeless population, linked here.² Many of these individuals do not have easy access to maintenance healthcare and end up resorting to emergency services for both acute and non-acute issues.

Numerous studies have shown that homeless patients are generally high utilizers of emergency services; according to the Center for Disease Control in the United States, there was an annual average of 42 ED visits per 100 non-homeless people between 2015-2018, compared to an average of 203 ED visits per 100 homeless persons in the same timeframe.³

So the question becomes: what are some of the special considerations that we, as emergency medical staff, should be weighing when treating homeless patients? Here are some tips:

1. Start thinking about disposition early, and, if your facility has access to them, get social workers involved as soon as possible. Take into consideration the closing time(s) of nearby shelters, and plan accordingly.
2. Discuss and document your patient’s social history thoroughly; this can not only help whatever further research that may be conducted but also help build better rapport with your patient. Ask whether they live in a shelter or on the street, for how long, transportation needs, etc., and be sure to document key findings.
3. Evaluate ability to perform activities of daily living, assess the level of functional independence and ambulatory capabilities.
4. Provide clothing, food, warm blankets, and mobility devices, when appropriate.
5. Assess access to follow-up healthcare. Familiarize yourself with the resources available: what are the organizations in your area that might be of help? Are there non-profits that work explicitly with the homeless population?
6. Discuss any potential substance abuse and attempt counseling.*

* In the United States, consider obtaining an x-waiver, which would allow you to prescribe buprenorphine. For more information about the significance of the x-waiver and information on how to obtain one online for free, click here.

7. Prepare discharge papers with clear, easy-to-understand instructions for follow-up and care. Avoid medical jargon and use comprehensible language; one recommendation suggests keeping language to a fifth-grader level.

Areas of improvement:

Each institution that deals with homeless patients will likely have its own protocols in place for its management. It is helpful to get acquainted with these protocols and to look around your emergency department to see if there is any room for improvement.

Below are some of the interventions which were undertaken, many of which ultimately showed a reduction in re-presentation and ED utilization, and could lead to an increase in patient satisfaction.

• transition of care: a review examining the effect of various interventions in discharging homeless patients found that all three studied categories (those being case management, individualized care plans, and information sharing) had a modest impact, with varying degrees of success based on different studies.⁴
• dedicated homeless clinics: a single-center study in 2020 found that a dedicated homeless clinic initiative reduced ED disposition failures and inappropriate ED visits, defined as seeking care for non-emergent conditions.⁵
• transportation considerations: while some hospitals are able to subsidize travel costs (taxi vouchers, shuttle service, etc.), that might not be possible at all institutions, so alternatives should be considered.

[A 2012 community-based participatory research approach was undertaken to understand how homeless patients (n = 98) reflected on their care. Of the patients surveyed, 42% mentioned that there had been no discussion of transportation, while 11% noted that they had slept on the street the night after discharge.⁶ This goes to show how important it is to discuss disposition early and thoroughly.]

• adding social determinants into electronic medical record-keeping systems: a paper reflected on the changes, such as adding fields for social determinants to the electronic health record (EHR) system, that were undertaken in Hawaii, USA.⁷ Some institutions tag their homeless patients in a certain way, but making changes at the EHR level could help integrate social needs into clinical care across multiple providers.

References and Further Reading

1. Chamie J. As Cities Grow Worldwide, So Do the Numbers of Homeless. YaleGlobal Online. https://truthout.org/articles/as-cities-grow-worldwide-so-do-the-numbers-of-homeless/. Published 2017. Accessed June 8, 2021.
2. Wikipedia. List of countries by homeless population. Wikipedia. https://en.wikipedia.org/wiki/List_of_countries_by_homeless_population#cite_note-1. Accessed June 8, 2021.
3. QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey. MMWR Morb Mortal Wkly Rep. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a8.htm. Published 2020. Accessed June 8, 2021.
4. Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department:A systematic review of interventions. PLoS One. 2015;10(4):1-18. doi:10.1371/journal.pone.0123660
5. Holmes CT, Holmes KA, MacDonald A, et al. Dedicated homeless clinics reduce inappropriate emergency department utilization. J Am Coll Emerg Physicians Open. 2020;1(5):829-836. doi:10.1002/emp2.12054
6. Greysen SR, Allen R, Lucas GI, Wang EA, Rosenthal MS. Understanding transitions in care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-1491. doi:10.1007/s11606-012-2117-2
7. Trinacty CM, LaWall E, Ashton M, Taira D, Seto TB, Sentell T. Adding Social Determinants in the Electronic Health Record in Clinical Care in Hawai’i: Supporting Community-Clinical Linkages in Patient Care. Hawaii J Med Public Health. 2019;78(6 Suppl 1):46-51. http://www.ncbi.nlm.nih.gov/pubmed/31285969http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6603884.