Published by: Jane Hooker on 8/10/2010 2:25:04 PM
The delicate dance between housing and health continues to fascinate and bewilder us. The frequent utilization of emergency rooms and hospitals by urban “rough sleepers” has challenged us to understand the obstacles and barriers to health faced by those struggling to survive each day on the streets of our cities.
Information about this elusive sub-population of homeless persons has been sparse, and this past December we completed a 10-year prospective study of a fixed cohort of 119 individuals living chronically on Boston’s streets. The deplorable results are a clarion call to all of us working in public hospitals and academic medical centers: despite an average age of 46 at the onset of this study, over 40% have died and another 10% are now permanently in nursing homes. The causes of death were primarily medical, with cancer and end-stage liver disease most common.
This crude mortality rate is among the highest known among vulnerable populations in America. Interestingly, this group had health insurance as part of the Massachusetts 1115 waiver obtained in 1996 as the first step toward universal health care in the Commonwealth. Medicaid data revealed that this cohort of 119 rough sleepers in Boston had over 18,000 emergency room visits during the first five years of the study.
We have been unable to escape this indictment of our current health care system: extraordinary access to expensive health care services yet overwhelmingly high mortality at such a young age.
As a doctor caring for Boston’s rough sleepers, I reluctantly accept that this glaring health care disparity is immune to our innovative service delivery models unless we learn to incorporate affordable supportive housing as a necessary (but not always sufficient) foundation for addressing this public health emergency.
Our current standards of care of chronic diseases such as diabetes and AIDS assume the presence of stable housing with family and community support. I have long dreamed of including a prescription for housing along with those for insulin or ART or an antibiotic for a pneumonia or cellulitis.
In the past few years, this recognition of health as intimately related to housing has led to the creation of low-threshold “housing first” programs across the country. These exciting programs have housed literally thousands of rough sleepers across the country, and most early studies have demonstrated remarkable reductions in the use of emergency rooms and hospitals. We are still learning about the services necessary for optimizing housing stability, and our hospitals and Medicaid programs will no doubt explore new ways to fund and sustain these services.
NAPH has been an innovative partner in this endeavor, recognizing the critical role of our safety net hospitals in partnering with housing and service agencies to eliminate health care disparities for these vulnerable populations. NAPH has joined with Common Ground and IHI in launching the 100,000 Homes Campaign, an exciting effort to house 100,000 chronic street individuals across America during the next five years.
In Boston, we have already seen almost 200 of our patients housed who had lived on the streets for years, and we have already seen their utilization of EDs and hospitals plummet. These next years will be the crucible, as we all struggle to assure that these individuals suffering from complex medical, mental health and substance abuse problems receive the needed services in their new housing.
My clinical life has radically changed to now include “house calls” to these individuals whom we had followed for years on the streets. Indeed, if past is prologue, I now remind myself of my family doctor who often visited us at home and who understood our living situation and all our family foibles.
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Dr. Jim O'Connell
President and Street Physician, Boston Health Care for the Homeless Program
Department of Medicine General Internal Medicine, Boston Medical Center
JOConnell@bhchp.org