Before reading any further, stop to think about the last older homeless adult you saw. If you are a clinician – think of the last older homeless patient you cared for – if you can remember the last time you had such an encounter in acute care settings such as the ED or hospital, even better.
Does this person you remember look anything like the gentleman pictured here?
...but here’s the catch: the odds are very good that you've met someone (maybe even provided clinical care for someone) who was without a home but you didn't know it because they didn't “look homeless.” In a study published this month in the Journal of Healthcare for the Poor and Underserved (JHCPU), my colleagues and I described the experience of acute care from the perspective of 100 homeless individuals seen in the ED or hospitalized over a 1 year period in New Haven, CT. We found that only 2 in 5 were ever asked about their housing status during the course of their care at the hospital. Not surprisingly, those who were asked were several times more likely to receive high-quality discharge planning based on their needs (e.g. discussions about costs of medications and transportation). Compounding the problem of using the “eyeball test” to determine who has unstable housing, many patients are hesitant to disclose their need for fear of discriminatory care or simply from embarrassment – this may be particularly true for older adults.
Our results were the result of a community-based participatory research project with Yale-New Haven Hospital and Columbus House, a robust homeless services organization that operates 2 large shelters in New Haven. Leveraging the strengths of this unique partnership, we also found that lack of coordination between the hospital and shelter was a major barrier to successful transitions for patients. As one patient explained, “miscommunication is a problem – sometimes the hospital sends you to the shelter, but you can’t get in.” Indeed almost 1 in 3 patients were discharged after dark and 1 in 10 spent their first night after discharge on the streets. Fortunately, data from this project led to a community taskforce including the hospital, shelter, city and state government to develop a respite care unit within the shelter for homeless patients requiring special care after discharge (such as daily wound care or IV antibiotics). A bill supporting this project passed the Connecticut State Legislature in Month and the respite unit will open this fall.
Many cities like New Haven are joining the movement to increase access for homeless patients to respite care after hospitalization both for reasons of quality improvement and cost reduction. In a systematic review also published this month in JHCPU by Kelly Doran, current Robert Wood Johnson Foundation Clinical Scholar at Yale and leader in the New Haven Respite Taskforce, shows that respite programs consistently reduce the length of hospital stays, hospital readmissions, and overall costs of care for homeless adults. Despite these encouraging results, there is still work to be done. Although the mean ages of patients enrolled in the 13 studies analyzed in this review were in the mid-to-late 40s, there were no respite studies with resources specifically geared for older homeless adults.
As the homeless population continues to age, improving the quality and continuity of care for homeless adults is becoming ever more important. As my colleague Rebecca Brown points out in a study published this week in JAMA Internal Medicine, the average age of homelessness has increased from 35 to 50 over the last 20 years and older homeless adults access acute care services at extraordinarily high rates. In a cohort of 250 older homeless adults in Boston, 2 in 3 visited the ED in the last year and almost 1 in 3 visited the ED 4 or more times. The presence of geriatric syndromes such as falls and impaired executive function were powerful predictors of frequent ED use. In another study published this month in JHCPU, she also demonstrates that even the “younger” adults in this “over 50” cohort are at high risk for these geriatric syndromes.
These findings have important and unfortunate implications for these patients as well as our healthcare system – an ED clinician looking at a 55 year old man with an injury or musculoskeletal complaint might not think to ask if he is homeless and might not consider the patient’s risk for geriatric syndromes. In medicine, appearances may be deceiving but this shouldn't prevent clinicians from making a difference for this population. Patients in our community-based study recommended that clinicians take a simple, patient-centered approach to assessing housing needs: rather than ask patients who “look homeless” the usual, pointed questions of “are you homeless?” or “do you have a permanent address?” acute care providers can simply and compassionately ask all their patients, “do you have a place to stay where you feel safe?” Personally speaking, I probably would never have guessed the gentleman pictured above – a former client at Columbus House shelter in New Haven – was homeless if I had met him in a busy Emergency Room. To provide the best possible care for this highly vulnerable population of seniors, our first and perhaps greatest challenge might just be to look past our preconceived notions to learn who these patients are.
By Ryan Greysen
Photo by Robert Lisak for Columbus House, Inc.