In 2018, the U.S. Department of Housing and Urban Development estimated that more than half a million people experience homelessness on any given night. Many find shelter in our emergency departments.
City governments across the country—such in as Los Angeles, New York City, and Boston—have mobilized significant resources to address homelessness by creating housing units meant for the homeless and implementing greater supportive services. The problem with this approach is that these city and statewide efforts don’t coordinate with the most crucial partner in the ecosystem of services that care for the homeless: hospitals.
The result is a cycle of missed opportunities that plays out nightly in emergency departments across the country.
Could the implementation of housing navigators—specially trained experts in housing placement who have been traditionally used outside of the hospital setting—as ED staff be the answer?
In the absence of more robust, permanent supportive housing units, I propose that there is no other intervention that could have a more significant impact on ED care for the homeless than implementation of ED-based housing navigators. Consider the recent case of a patient in our emergency department.
It was 2 a.m. and 2°F outside in Boston. We were about to discharge Terry (whose name was changed for this story) from our department for the second time in 24 hours. Terry was homeless, and this was our routine all winter last year, especially when it was too cold for him to sleep under a highway overpass or in shop doorways downtown. Many times, he was drunk, and so we monitored him until he was sober enough to walk out. Other times, he concocted medical issues that needed to be urgently evaluated, excuses that he (and we) knew would keep him in our emergency department safe and warm, at least for a few hours.
That night, my colleague was the provider caring for Terry. I showed her a list I’d been given of high utilizers of emergency services (and yes, the term “frequent flier” is derogatory). This list contained the top 50 homeless utilizers of the city’s emergency services, their housing status, and where they were on the path to being placed in city housing.
It is remarkable that the city even has such a list. But the city’s major problem? Due to the nature of homelessness, it has trouble simply locating these patients. A colleague who worked for the Department of Public Health thought that, as an emergency physician, I might be able to keep an eye out for patients on this list who presented to the emergency department. This particular list is one of nearly a dozen distinct housing lists that create a disconnected and complex patchwork of resources that weaves together the housing system in Boston.
My colleague’s eyes fixed on the screen. There was Terry’s name. Not only did he already have a housing voucher assigned to him, he also had a city-owned apartment waiting for his arrival. He had never checked in.
Later during that shift, we contacted Terry’s case manager, and while he was in the hospital, preparations were made for him to move in. He was later discharged. To his new home.
Terry’s case was exceptional in that the stars aligned. He happened to have available housing and an effective outpatient case manager. But his case is not unique. There are patients who are in the same situation as Terry. Sadly, hospitals that see these patients are often kept in the dark.
Usually, hospitals simply discharge patients like Terry back to the streets with a list of shelters. We don’t fundamentally advance them on the pathway toward housing. I hear you asking, should we? My answer is yes.
What We Can Do
After caring for Terry, I’ve often wondered how many cases like his I had come across in my practice. How many of these individuals whom I had seen actually had city and state housing opportunities simply waiting to be utilized?
Recently, analyses of the interplay between housing and health have prompted hospital systems to institute programs that address homelessness. Through these programs, successful institutions often find ways to identify homeless patients and then connect them to appropriate housing and ancillary services.
The methods vary. Some institutions rely on case managers to tack on extra workflows of basic housing navigation to their already overflowing list of responsibilities, while others use inundated social workers to perform these tasks. Data show that social workers or case managers combined with intensive housing assistance may be effective. But unfortunately, most social workers and case managers can’t or don’t solely focus on housing their patients. Thus, these benefits are often not sustainable. This fact, combined with the complexities of the housing sector, has pushed hospitals to introduce a new field of hospital staff: housing navigators.
Housing navigators are workers trained in helping advance the housing status of the homeless. They have been effective in contributing to higher rates of long-term housing permanency for the homeless. Traditionally, housing navigators have only existed outside of hospitals and only work in shelters or community outreach programs that address homelessness.
That is beginning to change as a growing number of hospitals and emergency departments are employing housing navigators who are helping to advance the housing status of our nation’s homeless.
In Minnesota, Hennepin Healthcare System created a program that leverages housing navigators. Its preliminary results? Emergency department visits fell 35 percent among their homeless high-utilizer population, and nearly 50 percent of their highest utilizers became stably housed. Similarly, in California, Hospital Harbor Interfaith Services partnered with South Bay Hospitals to create a housing navigator position that helps hospital social workers navigate the complex housing system for their patients. The results were so substantial that after only one year of implementation, partnering hospitals funded the program for an additional three years.
Minnesota and California are not alone in these endeavors. In New York, Mount Sinai Health System recently hired a housing navigator to help homeless patients transition to permanent housing, and Vanderbilt University Medical Center in Nashville also introduced a housing navigator in 2016.
What about the finances? The good news is that even payers have identified the utility of implementing housing navigators. UnitedHealthcare is employing housing navigators to work with emergency departments in Texas, Washington, and throughout the Midwest. For obvious reasons, they see the value.
Introducing emergency departments to housing navigators means that patients such as Terry will no longer have to rely on a slim chance of clinicians glancing at housing lists to claim the resources available to them.
Instead, homeless patients unaware of the resources available to them would be assessed by housing navigators and transitioned into housing opportunities at the city and state level or be triaged to transitional care, such as shelters, respite care, and adult foster care, when longer-term solutions are not immediately available. These housing navigators act as additional specialists who can help unburden busy ED providers who are not well-versed or trained in navigating their community’s housing ecosystem, let alone doing so at 2 a.m.
With the increasing administrative focus on social determinants of health, I strongly believe that hospital-based housing navigators can serve as powerful resources, not only to reduce health care costs but also, more important, to house people who frequently present to our emergency departments in search of temporary shelter.
Emergency departments have an opportunity to treat homelessness like any other medical problem by connecting homeless patients to the specialists they need most. The implementation of housing navigators is the first crucial step in doing so.
Dr. Martin is an emergency physician at the Center for Social Justice and Health Equity at Massachusetts General Hospital and Harvard Medical School in Boston. Mr. Plevyak is an anthropology student and Mr. Velasquez is a medical student at Harvard.
More Ideas for Helping Homeless Patients
Want more on social determinants of health? Check out the special Annals of Emergency Medicine supplement “Inventing Social Emergency Medicine: A Consensus Conference to Establish the Intellectual Underpinnings of Social Emergency Medicine” online. You’ll find a repository of work that will help you improve the health and lives of your patients by incorporating social context into your practice. Read the supplement.