How Healthcare Organizations Drive Homeless Patient Care Access

March 18, 2019 - As healthcare organizations continue to drive strong population health management, they must work to meet the medical and social needs of their homeless populations. In doing so, they can help improve patient care access for patients experiencing homelessness.

According to the American Academy of Family Physicians (AAFP), patients experiencing homelessness span a broad range of circumstances.

“Homeless persons are individuals without permanent housing who may live on the streets; may stay in a shelter, mission, single room occupancy facility, abandoned building, or vehicle; or who are in any other unstable or nonpermanent situation,” the organization wrote in a resource on health and homelessness.

“Persons may be considered homeless if circumstances force them to stay with a series of friends or extended family members, or if they have been released from prison or the hospital and do not have a stable housing situation to which they can return.”

As of December 2018, 553,000 individuals experienced homelessness across the country, according to the Department of Housing and Urban Development (HUD). And with that extraordinary number comes significant health issues.

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Patients experiencing homelessness suffer from the same chronic conditions as patients who are not homeless. However, it is more difficult for them to manage these conditions and access healthcare. Additionally, patients experiencing homelessness experience acute health concerns that are worse and more frequent than patients who are not homeless.

Adults who are homeless tend to die at a younger age than those who are not homeless, AAFP reported. Pediatric patients who are homeless tend to face obstacles in school and other areas of their lives, which can also hinder their health down the line.

Homelessness is a key social determinant of health that creates vast differences in how patients experience their care. Patients experiencing homelessness often struggle to access their care and coordinate with their healthcare providers.

Because homeless patients can be more costly to healthcare organizations and due to their heightened needs, medical professionals should consider the various strategies to connect this population to care. Instituting team-based care and community health strategies may help drive patient care access for homeless populations.

Identifying patients who are homeless

The first step to enhancing care for homeless patients is identifying them. This should happen during initial primary care visits, according to the AAFP.

“The physician and clinic staff should focus on demonstrating genuine interest, empathy, and respect in a warm, nonthreatening, nonjudgmental environment,” the organization said.

Providers may start by addressing the symptoms the patients have presented with and offering effective health solutions that will impact the patient’s day-to-day life.

“This will help to establish confidence and mutual trust and encourage the patient to return to the physician's office,” AAFP wrote. “Once trust and rapport are established, visits can focus on identifying an emergency contact and discussing the patient's more challenging social, medical, and mental health problems, and end-of-life issues.”

Healthcare organizations must institute the best systems to keep track of these patients. This will help drive follow-ups with the patient and allow other providers to understand the patient’s circumstances.

“Data is a big piece of this, too. Just figuring out who's homeless in our patient population,” explained Stephen Brown, who is Director of Preventive Emergency Medicine at the University of Illinois Health (UI Health). “It's significantly under-reported and that's one of the things we're advocating for – better reporting of homelessness. It's not coded right now very well.”

Using the above techniques to discover who may be experiencing homelessness and then entering that information into the EHR will be crucial. That will allow doctors to view who is homeless and refer those patients to the right services, Brown said. It will also tip doctors off to which patients may need different types of chronic care services.

Utilizing team-based care for homeless patients

Team-based care is touted as the gold standard for all patient populations, but it will be especially crucial for treating homeless patients. Team-based care strategies will ensure all providers are able to care for patients and will help target patients who access care unpredictably.

“An integrated, multidisciplinary health care team with an outreach focus, along with involvement of local and state agencies, seems best suited to address the components needed to ensure quality of care, to help make these patients self-sufficient, and to help them succeed,” AAFP explained. “Family physicians are well suited to manage the needs of the homeless patient, provide continuity of care, and lead these multidisciplinary teams.”

Care teams should include family physicians, hospital-based providers, as well as community health specialists and case workers.

Furthermore, healthcare teams may consider reworking care plans for patients who are homeless. This population is often difficult to get in touch with or locate, meaning it will be challenging to engage in follow-up care for these patients. Setting up short-term care goals will make it easier for physicians to track patient progress and be more engaging for the patient, AAFP noted.

A strong community presence will aid in carrying out care plans for homeless patients. Meeting the patient where they are will increase the likelihood that patients receive follow-up care, or at least the preventive care that will keep them healthier in the long run.

Mobile health clinics allow patients to visit providers where it is more convenient for them, allowing healthcare organizations to touch base with patients. Setting up school-based clinics can address needs for pediatric patients.

Additionally, community outreach programs at homeless shelters, food banks, employment offices, and other locations help patients connect with care.

“Multidisciplinary teams can also co-locate medical, mental health, and addictions services, coordinate vertical integration of components within the health care system (such as the clinic, health center, emergency department, and hospital), and facilitate horizontal integration with other key sectors, including the criminal justice system, after-jail services, social services, and housing,” researchers Howard K. Koh, MD, MPH and James J. O’Connell, MD wrote in a 2016 JAMA piece.

Using housing first to address homeless populations

While it is important to treat the medical issues homeless populations present with, it will be more important to address housing stability as a root cause of these conditions.

Housing first programs, which call on hospitals and health systems to address housing as a medical condition, have proven effective where implemented. Building off those successes, organizations across the country are working with community health partners to create more affordable housing options and connect their populations with them.

These programs are admittedly difficult and expensive to manage. But they have significant clinical payoff, according to UI Health’s Brown.

“If you begin to wear a lens of thinking that it's a dangerous health condition, then it just makes sense that hospitals would want to go beyond what they typically do, beyond delivering excellent medical care, and really move into a population health space,” Brown asserted.

But when an organization invests in housing, it ideally cuts costs driven by this complex population.

“A lot of hospitals were concerned about the plummeting rates of uncompensated care they have, and they were nervous that the IRS was going to scrutinize them because of community health needs assessment findings,” Brown concluded. “This is a good program for hospitals to feel good about themselves, that they're actually impacting the health of the residents in the community that they serve.”

As healthcare organizations continue their population health management strategies, they must acknowledge both the medical and community health components. While treating the symptoms and health needs of populations will be key, as will be addressing the social determinants of health with community health programming.