Park D, Bonagiri P, Lee N. The COVID-19 pandemic and addressing homelessness in healthcare. Harvard Public Health Review. 2021; 30.
According to the United States Department of Housing & Urban Development (HUD) annual point in time report, on any single night in January 2019 an estimated 567,715 Americans (17 of every 10,000 persons in the U.S.) were estimated to be homeless. Unsheltered homelessness has increased over the past 5 years, affecting every racial group, with women experiencing a 12% increase and men experiencing a 7% increase from 2018 (The 2019 Annual Homeless Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness, n.d.). Homelessness predisposes individuals to illnesses and exacerbates pre-existing health conditions. The perils of homeless living have also led to increased mortality rates. The CDC estimates that persons experiencing homelessness are at a 1.5 to 11.5 increased risk of mortality when compared to the general population (Doshani, 2019). The life expectancy of the average homeless person is estimated to be 42 to 52 years, while that of the general public is 78 years (National Coalition for the Homeless, n.d.). Historically, homeless populations have been particularly susceptible to disease outbreaks and the COVID-19 pandemic has highlighted the perils of unsheltered living. It is of vital importance for homelessness to be addressed from a healthcare perspective in order to ensure health standards for one of the nation’s most vulnerable populations. One such method to stem the increasing rates of homelessness are the Housing First initiatives piloted by several large cities. The Housing First operations have decreased emergency room use, healthcare costs, substance abuse, and increased access to care. This manuscript was written with the intention to educate and raise awareness of healthcare policy that addresses homelessness from a public health perspective.
Health & Barriers to Health
An increasing population of homeless persons combined with unsafe living conditions and few opportunities to alleviate these circumstances have led to outbreaks of infectious diseases within the homeless community. The recent COVID-19 outbreak is a reminder of the critical role accessible healthcare can serve in preventing detrimental outcomes. Health departments have made successful efforts to decrease transmission throughout the homeless community by providing temporary shelters. There is nevertheless a greater mortality risk due to pre-existing conditions and immunocompromised states aggravated by unhygienic living conditions (Lima et al., 2020). A recent attempt to track COVID-19 related deaths in the homeless population through official records indicated just 373 deaths (“COVID-19 Homeless Deaths,” n.d., p.). This is thought to be a significant undercounting. A recent study indicated that COVID-19 mortality rate was 75% higher in New York’s homeless population compared to the city rate (“Age-Adjusted Mortality Rate for Sheltered Homeless New Yorkers,” n.d.). In San Francisco (SF) homeless deaths were reported to have tripled since from March 30th to May 24thwhich coincides with the arrival of the coronavirus pandemic (“The Uncounted,” 2021). Though some of the homeless that died tested positive for COVID-19 close to the time of their death, the exact causes of death are under investigation and have not been counted as COVID-19 fatalities per the SF Department of Public Health.
During a Hepatitis A virus (HAV) outbreak in San Diego, between November 22, 2016 and June 21, 2018, there were 590 confirmed cases. The primary risk factors were determined to be homelessness and illicit drug use (194 cases, 34%) and homeless alone (91 cases, 15%). The strain of Hepatitis A causing disease in San Diego was genetically linked to strains in Santa Cruz, Los Angeles, Arizona, and Utah (Wooten, 2019). Further examples of outbreaks in the homeless include typhus in Los Angeles and shigellosis in Oregon (Hines, 2016),(Porse, n.d.). The aforementioned diseases are occurrences of outbreaks in the homeless community and do not include the common communicable diseases seen in this population such as HIV, tuberculosis, Hepatitis B, hepatitis C, and STIs. Homeless persons must reckon with their unsheltered status on a daily basis as it permeates every aspect of their lives. These disease outbreaks illustrate how their medical burden is also exacerbated by their homeless status.
Barriers to healthcare for homeless persons are comprised of various logistic factors. Homeless populations experience lower literacy rates, lack of transportation, limited ability to communicate through phone and internet, and reduced access to healthcare facilities and professionals. Simple considerations such as bus fare and a hospital within walking distance become significant hurdles. These barriers to healthcare exacerbate chronic health conditions such as HTN, diabetes, etc. by limiting the ability of homeless individuals to meet appointments with healthcare providers and laboratory testing centers (Mcenroe-Petitte, 2020).
Housing First Initiatives
The precipitating and exacerbating factor of many health conditions in the homeless populations is the mere condition of being homeless. Since 1988, programs to housing the homeless through various initiatives is a solution being offered in many states and has found success. The Beyond Shelter Homeless Program in Los Angeles is a perfect example of these initiatives. It transitioned homeless individuals into permanent supportive housing as opposed to traditional homeless shelters. The program further offered individualized case management services for up to one year. Since initiation of the program over 750 high risk homeless families have been assisted in finding permanent housing. In addition, 28% of these individuals obtained employment and 32% saw increased incomes (Angeles, n.d.).
The success of The Beyond Shelter Homeless Program heralded the start of the “Housing First” assistance programs in the United States. Housing First marked a shift in social policy for rather than shuffling homeless patients through increasing levels of independent housing, e.g. homeless to shelter, shelter to housing program, housing program to apartment, an individual would be immediately placed into their own living space.(Housing First, n.d.) A 2016 review study indicated that Permanent Supportive Housing Medicaid costs for homeless individuals dropped $1,626 per month to $899 per month one year after move in, decreased substance abuse, improved access to care, reduced psychiatric symptoms, and improved overall well-being (Rapid Evidence Review: What Housing-Related Services and Supports Improve Health Outcomes among Chronically Homeless Individuals? | AcademyHealth, n.d.).
Currently, Housing First Initiatives are active in New Orleans, Louisiana; Plattsburgh, New York; San Diego, California; Anchorage, Alaska; Salisbury, Maryland; Minneapolis, Minnesota; Charlotte, North Carolina; Chicago, Illinois; Denver, Colorado; San Francisco, California; Atlanta, Georgia; Quincy, Massachusetts; Philadelphia, Pennsylvania; Salt Lake City, Utah; Los Angeles, California; Austin, Texas; and Cleveland, Ohio. Based off the Housing First assistance program, the University of Illinois and the Center for Housing and Health founded the ‘Better Health Through Housing’ program in 2015. Early results of the program indicated a 35% reduction in use of the emergency department and an increase in patients accessing clinics for more routine care. Financially, the program has drastically reduced healthcare costs. University of Illinois Health reported approximately 200 of their chronically homeless patients fell into the top 10% for patient cost, representing an annual per patient cost of $51,000 to $533,000. Through their housing initiative they saw a calculated 67% reduction in cost with the exclusion of one outlier–an individual receiving end of life care (American Hospital Association, n.d.).
Furthermore, the University of North Carolina reported that Housing first initiatives in Charlotte, North Caroline led to $1.8 million less in medical expenses during the first year of housing when compared to the previous year. The decrease represented a 70% reduction in emergency room use. Tenants of the program visited the emergency room 447 fewer times and were hospitalized 372 fewer times. Per tenant, hospital bills dropped $41,542 to $12,472 (Moore Place Permanent Supportive Housing Evaluation Study | Research | SHNNY, n.d.). Housing First emphasizes that the initiative must focus on more than simply housing and that case management and supportive services are necessary to addressing the diverse issues of each individual. Economically, the initiative has demonstrated the ability to reduce healthcare costs and provide a positive medium for homeless persons to greatly alter their lives.
A meta-analysis of randomized controlled trials in the Journal of Epidemiology & Community Health analyzed the effects of Housing First on health and well-being. Baxter et al. determined Housing First initiatives contributed to fewer emergency department visits (incidence rate ratio (IRR)=0.63; 95% CI 0.48 to 0.82), fewer hospitalizations (IRR=0.76; 95% CI 0.70 to 0.83), and less time spent hospitalized than control groups (standardized mean difference (SDD)=1.24; 95% CI 0.86 to 1.62).(Baxter et al., 2019) This meta-analysis did not include participants from the aforementioned University of North Carolina, Housing First Initiative. Of the four studies this meta-analysis analyzed, two studies included participants from Illinois. One study’s participants were from John Stroger Hospital of Cook County and the other study’s participants were from an unnamed public teaching hospital and a private, nonprofit hospital in Chicago.
Housing First faced criticism from the Trump Administration in 2020 and faced a challenge with the proposal of “Expanding the Toolbox: The Whole-of-Government Response to Homelessness”. This proposed shift in policy was brought upon by the thought that despite an increase in permanent service housing, homelessness has continued to rise nationally. The United States Interagency Council on Homelessness proposed requiring job training and treatment programs to housing vouchers (Little, 2020). This proposition was in contrast to Housing First principles as requirements such as these would assume a “one-size-fits-all” path from homelessness to housing. Housing First does not preclude individuals from housing regardless of their history and participants are not required to participate in services to receive or retain housing. National homeless advocacy groups were quick to condemn this proposed shift in policy with the National Alliance to End Homelessness writing a statement in response, “…this document is neither strategic nor a plan…”. Eric Tars, Legal Director for the National Homelessness Center stated, “You can give all the job training programs that you want. But if the jobs aren’t there, it’s not fair to blame the individual.” The proposed shift was concerning as it did not seem larger socioeconomic and systemic factors attributing to homelessness such as increasing joblessness and rising housing costs relative to income were considered.
Another limitation of Housing First has been appropriately funding permanent service housing. A principle of Housing First is that ‘no two people experience homelessness in the same way’. Therefore, it is to the discretion of the state and city to implement Housing First with their own specific guidelines to adequately implement permanent service housing in a manner most conducive to assisting their particular homeless population. The Licton Springs Housing First village in Seattle was developed with an eligible lease of two years; however in order to be eligible for the second year, the village needed to prove the capability of transitioning residents to permanent housing (Davila, 2018) . The activist group managing the village, SHARE, reported they did not have adequate funding in order to partner homeless individuals with case managers and were unable to meet the transition rate determined by the city. This housing village has since been closed and represents how limited funding can be detrimental to the success of the operation. The Housing First model advocates Housing First (Not Housing Only), supportive services are integral to understanding the unique situations of those in permanent supportive housing in order to address their social, economic, and medical needs. This principle of Housing First when not properly addressed may lead to failure of a housing service. A benefit and limitation of Housing First is the broadness of its principles. States, cities, and organizations have broad Housing First principles to base the development of their housing operations; however, there is no concise manner in which each entity is encouraged to accomplish their task. This is in part due to each entity best understanding their unique population and resources available. Yet, it is seen in the case of Licton Springs how Housing First principles without appropriate execution may lead to failure.
Homeless individuals are a vulnerable population and their status of being homeless must be viewed from the lens of a healthcare perspective in order to provide safety and address health needs. Homelessness is increasing in the United States and so are the associated healthcare challenges. From increasing disease outbreaks, violence, and the logistic difficulties to managing health, measures must be taken to prevent and improve health outcomes. The expansion of Housing First initiatives is an important part of the puzzle and a great first step in answering the greater question of how best to provide healthcare to the homeless.