FOREWORD: Homeless Use of Emergency Departments
In this foreword to an observation article by Ariana Luterman, Journey Dreyer writes about the epidemic of homelessness in the United States and the unique relationship between the homeless population and emergency departments.
In the United States, a lot of freedoms and rights are given to citizens that provide them with the ability to do everything from speaking their mind to obtaining the license for a gun. What U.S. citizens have not always had the right to was freely entering an emergency department (ED) without giving consideration to the cost of that visit and their health requirements. Until 1986, the right to unfettered access to emergency medicine did not legally exist in the United States. U.S. EDs had previously had the right to turn away patients that were not seen as financially beneficial or too financially risky. This practice was put to an end when Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) that ensured public access to emergency services regardless of their ability to provide payment. Moreover, it requires that all Medicare-participating hospitals with emergency departments treat and screen all patients with emergency medical issues in a non-discriminatory method. The hospital must go through this process regardless of the patient’s insurance status, ability to pay, race, gender, etc. until the emergency situation is resolved or the patient is stabilized (Rosenbaum, 2013). While this allowed many doors to open up to uninsured individuals, the backlash of free access is the extent of overuse and abuse of ED resources nationwide. It is the homeless population in the U.S. that benefits from EMTALA the most. Those individuals would otherwise have limited or no access to necessities that most people take for granted, such as health care, housing, medical facilities, food, and social support.
Homelessness in the United States has been, and continues to be, a major issue. The historically shifting and changing definition and understanding of the term “homeless” is problematic itself. When the term was first used in the 1870s, it was meant to describe those people who were traveling across the country in search of work. It emphasized a “loss of character and a perceived emerging moral crisis that threatened long-held ideas of home life, rather than the on the lack of a permanent home” (Appendix B, 2018, p.175). As industrialization spread and mobility led to young men moving across the country in search of jobs, the number of people living in slums and tenements increased. Often romanticized in American literature, the culture of migrant workers faded into the early twentieth century as companies began to value long-term workers. World War II led to a drastic and widespread economic surge. As jobs increased over the following three decades, those who experienced homelessness were disproportionately white, male, over 50 years old, disabled, not economically independent, and residing in cheap hotels or single room occupancy hotels (SROs) located in the poorest neighborhoods and Skid Row areas of urban America (Appendix B, 2018, p.176).
The 1980s began the era of homelessness that the United States now faces today. The recession that hit the U.S. during the decade was the worst the country had faced since the Great Depression. Low-income housing and Skid Row areas vanished as SROs and rooming houses available to the homeless were replaced by apartment complexes and condominiums. Rents increased, and have continued to increase, as wages remained fairly stagnant. Other forces that led to a change in homelessness during this period, and have impacted homelessness as it is seen now, include inner city gentrification, deinstitutionalization of the mentally ill, increased and high unemployment rate, and major budget cuts to the U.S. Department of Housing and Urban Development among other factors (Appendix B, 2018, p. 177). Many changes in U.S. policy also caused the proportion of homeless people that have mental health issues to increase.
The history of homelessness in the U.S. is extensive yet “the homeless story,” as Charles Hoch calls it, explains some of the key social factors that lead to the epidemic that is homelessness. The homeless story has many different versions, often competing with each other, that attempt to explain the underlying causes of homelessness. The narrative that people lose social standing and fall into a condition of social dependency has overpowered the much more realistic and prevalent issue that resides in the treatment and classification of homeless individuals by shelter providers, social workers, and advocates (Hoch, 2000, p. 865), as well as exploitive employers, abusive family members, and landlords. More often than not, homelessness is directly tied to alcohol and drug abuse which not only leads to social stigmas surrounding homelessness, but also leads to the necessity for social and medical aid that, because of their lack of resources, homeless individuals do not have access to, except for the one place where they cannot be turned away: emergency departments.
Not only must EDs shoulder a large burden due to the economic implications of frequent homeless patient use, but also because of the social implications of individuals who, due to their circumstances, have little to no social support or positive social interaction. The purpose and function of the modern ED is called into question with regards to the responsibilities of doctors and the extent to which they treat not only the medical conditions of their patients, but rather the social factors that are leading to a multitude of medical crises. The significance of social factors impacting health issues increases in considering the medical response to problems patients face. A study regarding social emergency medicine published in the Annals of Emergency Medicine emphasizes the interplay between social forces and the emergency care system and creates a framework for a medical and social safety net (Anderson, Hsieh & Alter, 2016, p. 21). The study stresses the importance of emergency medicine as the answer to the societal need for equal access to medical care for all patients regardless of socioeconomic status. However, users of emergency medicine resources are disproportionately impoverished patients with unmet social needs. The goal of social emergency medicine is patient intervention “both before and after they become medically and socially complicated frequent visitors” (Anderson, Hsieh & Alter, 2016, p. 22). The importance of noting the use of the term “frequent” cannot be overstated, because it relates directly to the ability of an ED to efficiently treat as many patients as possible, the demographic of patients who are repetitive users of emergency services, and the problems that arise due to the frequency of patients who may not require so much as desire the care provided in EDs nationwide.
In some situations, the homeless use of EDs is less a burden and more so a simple human kindness. A question that residents, who more often are actively seeing patients in comparison to attendings, must ask themselves is how far the social care of a patient should go beyond the medical. While some doctors claim that the social needs of a patient are not their responsibility and is rather the responsibility of social workers and other care providers, the large majority claim that taking care of the social needs of patients is integral to emergency medicine and that helping to bring some comfort and aid to people who are in need of it is a rewarding experience (Doran et al., 2013, p. 358). Moreover, in the business of emergency medicine and the treatment of acute situations, social emergency medicine is key to understanding the underlying causes of problems the homeless face and how to provide help beyond the immediate care given in the ED. In order to improve population health there are certain barriers that must be acknowledged when intervening in ED functions. In order to increase overall population health through social emergency medicine, only methods and interventions proven to be beneficial should be implemented, local barriers must be recognized and understood, any form of intervention has to be modified in order to be optimal for the local culture, and sources of funding outside of the hospital must support the initiatives that are seen as necessary or valuable (Anderson, Hsieh & Alter, 2016, p. 22).
Repeated ED use tends to be associated with socioeconomic distress, chronic illness, substance and alcohol abuse, and psychiatric disorders, which means that not only must the treatment considered for each patient be for immediate symptoms, but also must consider the long-term. Due to EMTALA, patients cannot be turned away and cannot be discharged unless they are stable, however, this is in relation to both physical symptoms the patient may have as well as any psychological issues. When patients are considered a threat to themselves or others then they cannot be discharged, and will often be held in emergency facilities until they are cleared. In some cases, homeless individuals who are aware of the regulations imposed upon the hospital are able to take advantage of them and claim to have psychological problems that result in their extended stay in the ED (Doran et al., 2013, p. 356). The increased use of EDs in the United States over the past several decades has increased the attention towards the impact of frequent users. In a study regarding the urban homeless as super-users of the ED, individuals were found to have a relative risk of frequent use of 4.5 times that of the non-homeless (Ku et al., 2014, p. 366). The absence of a universal health care system in the United States causes the EDs nationwide to exist as the safety net for its population.
While there are varying causes for the higher rates of repeated use of EDs by homeless individuals, several underlying causes include lack of social services provided or access to those services outside of an emergency medical facility. Other reasons include lack of out-patient care and long-term solutions during discharge of patients, substance and alcohol abuse within homeless populations, chronic illnesses, psychiatric disorders, and even cold weather. Additionally, other predictors of ED use include comorbidities (the simultaneous presence of two or more conditions or chronic illnesses), crime, and food insecurity (Doran et al., 2013, p. 355). Without giving consideration to the social or moral good that is done in going beyond what is required of medical practitioners in EDs in their treatment of homeless individuals, the financial burden alone raises into question the capability of these facilities to remain both vital medical as well as social service providers. If underlying causes of homelessness could be targeted, not only would the secondary problem of overcrowding be eliminated within EDs, but discharge planning could be improved. A step towards this improvement would be to implement a system of categorization of homeless patients implemented in facilities so as to reduce the high frequency of ED visits by portions of the homeless population (Ku et al., 2014, p. 366). Discharge planning with regards to providing aid and guidance in finding shelter that is not temporary is key in not only reducing homeless use and the monetary cost of ‘frequent fliers,’ but also in targeting homelessness itself.
A solution that has been proposed (beyond the integration of social emergency medicine systems, improved out-patient care, and better informed discharge planning for homeless individuals) is the implementation of programs that target homelessness and its underlying causes. Housing first programs have been implemented globally and the success of these has been researched and analyzed in order to see the effect they have had on local populations and homelessness. The Housing First model is non-abstinence-contingent, which makes it unique, especially for people struggling with substance abuse. This program provides permanent housing to homeless individuals who use ED services frequently. Some concerns are that the health benefits connected with the program go unused because people do not have to stop using drugs or alcohol in order to have access to the program. People who take advantage of this program but do not simultaneously deal with substance abuse issues won’t be able to get the full benefits the program has the ability to provide. This study shows that this program can successfully improve housing stability and may improve some aspects of health as well (Baxter, Tweed, Katikireddi & Thomson, 2019). Outpatient care as a basis for aiding the homeless and preventing the recurring necessity for emergency services, both social and medical, is at the forefront of thought with regards to this and other housing programs.
Homelessness has its foothold in history and is imbedded so deep into society that at first glance the problem seems insurmountable. However, the problem is not homelessness in isolation but the causes of homelessness and the stigmas that result from false perceptions of what being homeless means and what it entails. As a country that prides itself on upholding the rights every person has to certain freedoms, the United States has taken steps forward at a government level with regards to access to health care providers while also allowing the roots of the problem to go unacknowledged and persist nationally. This is due in part to the lack of willingness for the United States to accept, as a country, accountability and responsibility for the lives and well-being of those who have very little support and face challenges that are simply out of their control. The following article highlights the issues that emergency departments in the US face as a whole, with homelessness overuse and dependence existing as small facets to a larger societal problem. The acute medical care and immediate social necessities fulfilled by EDs across the U.S. are only the band-aid on the broken leg of the institutional and social issues in the US. The country must confront and deal with these major problems before any real changes can be made and this nation of liberty has reached a point of no return.
Anderson, E. S., Hsieh, D., & Alter, H. J. (2016). Social emergency medicine: Embracing the dual role of the emergency department in acute care and population health. Annals of Emergency Medicine, 68(1), 21-25. doi:10.1016/j.annemergmed.2016.01.005
Appendix B: The history of homelessness in the united states. (2018). Permanent supportive housing: Evaluating the evidence for improving health outcomes among people experiencing chronic homelessness, 175-182. Washington, DC: The National Academies Press.
Baxter, A. J., Tweed, E. J., Katikireddi, S. V., & Thomson, H. (2019). Effects of housing first approaches on health and well-being of adults who are homeless or at risk of homelessness: Systematic review and meta-analysis of randomized controlled trials. Journal of Epidemiology and Community Health. doi:10.1136/jech-2018-210981
Doran, K. M., Vashi, A. A., Platis, S., Curry, L. A., Rowe, M., Gang, M., & Vaca, F. E. (2013). Navigating the boundaries of emergency department care: Addressing the medical and social needs of patients who are homeless. American Journal of Public Health,103(S2), 355-360. doi:10.2105/ajph.2013.301540
Hoch, C. (2000). Sheltering the homeless in the US: Social improvement and the continuum of care. Housing Studies, 15(6), 865-876. doi:10.1080/02673030020002582
Ku, B. S., Fields, J. M., Santana, A., Wasserman, D., Borman, L., & Scott, K. C. (2014). The urban homeless: Super-users of the emergency department. Population Health Management, 17(6), 366-371. doi:10.1089/pop.2013.0118
Rosenbaum, S. (2013). The enduring role of the emergency medical treatment and active labor act. Health Affairs, 32(12), 2075-2081. doi:10.1377/hlthaff.2013.0660