When Martha (names have been changed), arrived at the emergency department with her eleven year old daughter, Micca, she explained that her daughter had been struggling with severe digestive pain over the past few days. But after Micca was admitted, and food was offered, the nurse noticed how quickly both mother and daughter devoured their food—readily accepting a second helping when offered.
Although both appeared in faded, but clean clothes, the nurse mentioned to the doctor that they might be homeless. Knowing this, the doctor assigned a caseworker to talk with the two as part of the visit.
The Current State of Homelessness
According to a report by the National Center on Family Homelessness, roughly 3.5 million people—and 2.5 million children—in America experience homelessness each year—meaning one in every thirty children will face holidays without secure shelter.
Homelessness, and the stresses associated with it, can cause a number of health problems in both children and adults. High blood pressure, influenza, gastroenteritis, tuberculosis, and sexually transmitted diseases are among the physical ailments that regularly affect homeless populations—not to mention the high rate of mental illnesses that often accompany these conditions. The Healthcare Cost and Utilization Project suggests that 60 percent of all ED visits from homeless populations involve a mental health or substance use disorder, including mood disorders, alcohol-related disorders, schizophrenia, and other psychological disorders.
Yet without a window into the patient’s social determinants of health (SDOH), correctly identifying and effectively treating these conditions can pose difficulties. Many homeless populations hesitate to disclose homelessness—listing addresses of family members, shelters, or even imaginary places to avoid stigmas or judgement. Disclosing such determinants can bring consequences for families—including children having to change schools due to new addresses (or lack thereof) or social services interventions.
Identifying Patients with Social Determinants of Health
SDOH determine 80-90 percent of patient outcomes, according to the National Academy of Medicine. Knowing this, care teams will only be able to successfully help patients when they are able to identify and address these hidden SDOH.
Reviewing patient histories while looking for common illnesses associated with homelessness is one way to identify possible social determinants of health. When these histories are combined with care histories from other providers through a collaborative care platform, patterns of homelessness can become even clearer as care teams can quickly identify patterns of high ED utilization throughout the area.
Finally, turning attention away from the charts, and to the patient, can help care teams identify behaviors in the hospital that provide clues into possible SDOH. For example:
- Homeless patients may frequent the ED more often during inclimate weather—often with chief complaints that seem to resolve themselves when the patient it comfortably situated in a room
- Patients with food insecurity may present with minor complaints, then request multiple servings of food for themselves and any family members who are present once admitted
- A patient with low literacy may continue to return to the hospital for conditions that could have been treated by properly taking prescribed medications or following discharge instructions
- Cuts, bruises, or nervous behavior could signify an unsafe living condition and possible abuse at home
By being cognizant of patient cues in the hospital—and sharing patient info between providers as appropriate—care teams can get a fuller understanding of the patient, identify patterns of SDOH, and make plans to address those determinants for better overall patient outcomes. At Providence in Portland, Oregon, care teams addressing SDOH were able to not only reduce homelessness for their patients, but reduce ED utilization by almost half of these homeless patients by 50 percent.
Steps for Change
While no care team can completely address SDOH overnight, there are steps every team member can take to affect change.
Readjusting existing attitudes toward homelessness and other SDOH can alleviate the strain of stigmas that these populations feel, encouraging them to be more open about their current situation and help needed. While some believe SDOH stem from laziness or apathy, it can be helpful to know that mental illness often contributes to a person’s inability to hold a stable job or home.
In addition, the National Low Income Housing Coalition has published a study showing that no states currently offer a minimum wage high enough for someone who works 40 hours a week to be able to afford even a small two bedroom apartment. Even more striking is that only 7 of the 50 states offer housing inexpensive enough that it could be afforded with less than an 80 hour work week at minimum wage. These low wages and high rents also contribute to the over 12 percent of Americans that struggle with food insecurity throughout the country.
Although it’s impossible to implement a program that completely addresses SDOH for patients overnight, as care teams take the time to utilize the resources they do have—patient histories, coordinated care plans, observation, and empathy—patient care for those with SDOH will improve. And gradually, as care teams better provide for these patients, they’ll learn better ways to help address SDOH, too—leading to healthier patients and fewer homeless families during the holidays.
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