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The Challenge and Necessity of Providing Health Care for People Who Are Homeless

The community care team in Middlesex Hospital on July 11, 2017. They have representatives from hospitals, social services, and behavioral health agencies, and coordinate care for people who use emergency departments frequently. Photo by Ryan Caron King for NENC


To prepare for an outdoor church service last month, volunteers at Shiloh Baptist Church knocked on every door within a 10-block radius of the Hartford, Connecticut church.

They weren’t proselytizing, per se. Instead, they were trying to draw their Clay Arsenal neighborhood’s attention to the health fair after that June service. The fair would feature mammograms and screenings for blood pressure, as well as bounce houses for kids. The church pastor, the Rev. Maurice S. Porter I, knows that in order to draw people in, the church must offer attractions people will enjoy – like home-cooked meals and music.

Despite its proximity to St. Francis Hospital and Medical Center, and the amenities of downtown Hartford, Clay Arsenal is under-served, a neighborhood where just over 44 percent of residents live below the poverty level.

As the service started, a tall man in khaki limped by and said, “God has blessed us with another day of service.” Church members said the man frequents their soup kitchen. He has told them he is homeless. Several people who would be coming to the health fair are homeless. They come from a nearby shelter, House of Bread, or walk over from the train station.

The church is committed to its neighbors — those housed and not housed — but they know that providing quality health care to people who are homeless is challenging on every level, and that not providing it is immensely expensive.

Health fairs like this one are important for the individuals who avail themselves of the screenings, and for keeping public health care costs down. Many people who live on the streets seek health care only when they desperately need it. If a person who is homeless cuts his leg, he won’t go to his doctor. He mostly likely doesn’t have one. Instead, he waits until the cut becomes infected, and he drops on the street, at which point someone calls 911 and an ambulance comes to collect him, and take him to the local hospital’s emergency department.

And that’s an expensive way to get health care. Every year, the average person who is homeless will visit an emergency department five times.

The highest users visit weekly.

One Connecticut health care team identified a 53-year-old man who was homeless and living with alcoholism, diabetes, and hypertension who’d visited the same hospital 110 times in one year. People who are homeless visit emergency departments most often are sometimes known as “super users” for the frequency with which they visit. In 2010, the New England Healthcare Institute said that overuse of emergency departments accounts for $38 billion each year. The figure most likely has increased since.

Factor in mental health issues, and the costs are even higher.

But what can you do with a clientele whose attentions are devoted to day-to-day survival, not preventive or even follow-up care? Not long ago, lacking an alternative, hospitals throughout New England would release patients who were homeless back onto the streets – with predictable results.

“We had people recovering from surgery, out having to walk around New London,” said Catherine Zall, executive director of the New London Homeless Hospitality Center in Connecticut. “It was just crazy.” Occasionally, someone would show up at the shelter still dressed in hospital johnnies. As might be expected, re-admissions were frequent, especially among people who were also dealing with mental health issues.

In recent years, as states have drastically reduced their homeless population, architects of anti-homeless programs know that health care plays a huge role in getting and keeping people housed. Zall’s shelter offers respite care. Other municipalities offer health care geared specifically to people who live on the streets, or are at risk of doing so.

Since 1985, Boston has had the renowned Boston Health Care for the Homeless Program.

Dr. James O’Connell, organization president who also teaches at Harvard Medical School, is the driving force behind the program, which last year served 12,000 people on the streets.

New Hampshire, too, has a health care for the homeless program, which offers clinical care in two locations in Manchester. No appointments are necessary, and no one is turned away for an inability to pay. A similar program operates in Burlington, Vermont, and offers medical, dental, and behavioral health care.

The answer to homelessness will always be housing, but for some, housing must come with support services, particularly health care. That’s not cheap, but it’s still less expensive than ignoring the most vulnerable. A recent report from San Francisco said that costs of health care services — physical and behavioral — tend to rise dramatically among people who’ve been housed recently, but the increase (mostly from more-expensive emergency department visits) dropped within a few years as people began seeking preventive care.

In New London, Zall is focusing on health outcomes for clients with chronic diseases such as diabetes. The American Diabetes Association suggests housing as the first step to treat a person who is homeless and diabetic.

“We’ve invested so much in high-tech health care, and not enough in social determinants,” such as diet and housing, said Zall. “Here we are sitting at the Hospitality Center with hundreds and hundreds of people who are quite sick and no access to address social determinants. It’s hard to control what you eat when you’re dependent on what the soup kitchen is serving that day. And there’s also the whole issue of managing your medication, taking your blood sugar – all those things would be dramatically easier if you were housed.”

Zall hopes to collect enough information to make the case locally that housing improves health outcomes. It’s one thing to say it. It’s another to prove it with data.

In addition, in Connecticut, community care teams whose members represent hospitals, and social service and behavioral health agencies have “played a substantial role” in coordinating care for people who use emergency departments frequently, said Lisa Tepper Bates, executive director of Connecticut Coalition to End Homelessness. One of the challenges remains a lack of housing for the clients.

Prior to the teams, which began about five years ago, “we worked very hard but not collaboratively,” said Terri DiPietro, who coordinates the Middlesex County community care team with 14 providers, including Middlesex Hospital. “We talk to each other, not about each other. What I learned early, most providers had no idea how often their patients were come to the ED,” DiPietro said.

Zall said she is compiling information for the day when someone wants to invest in more formal data collection. She called it “hopeful preparation.”

“If those things can’t be addressed, the day-to-day routine of taking care of yourself becomes even more challenging,” Zall said. “We need to think holistically.”

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