Homelessness in America 

John is a 28-year-old male. In his early 20s he was in college and living with his girlfriend. At that time, he began going through periods of extreme depression and was unable to get out of bed and then would cycle to hyper manic states where he couldn’t focus in class and would make inappropriate outbursts. He was on insurance through college and went to a doctor who diagnosed him with bipolar disorder. He was put on medication at that time. However, the college did not have a medication plan, so he quickly ran out of money to afford the medicine and began the same cycle. Due to this he quickly flunked out of school. 

He got a job at a grocery store that did not have insurance benefits, so he was unable to get any medicine. After 6 months he lost that job, and his girlfriend broke up with him due to his increasingly erratic mood. He found himself living in his car. He got a job at a gas station and was allowed to keep his car there so he could work and live. He could only afford minimal food due to his part-time wages and most of that was through his discount at the gas station, so it was not very healthy. Due to this he started to develop some concerning numbness in his fingers and would find himself overly tired. One day the owner of the gas station found him passed out in his car. He was taken to the hospital via ambulance where he was placed on life support and his blood sugar was found to be in the 300s. He was put on insulin and given his psychiatric medicine. Once he was “healthy”, he was discharged back to his car and his work at the gas station.

Very soon his mood fluctuations became worse and his work sluggish due to his inability to get insulin to control his blood sugar. He lost his job and his car ended up being towed. Since he did not have money to get his car out of the impound lot, he found himself sleeping on the street and begging for any money he could get. About once a week he would go into the hospital where he found that if he threatened suicide, he could get a bed and a meal for a night while he was on suicide watch. His moods became increasingly erratic, and he would find himself taken into police custody after calls from various people calling his behavior suspicious.

His health continued to decline, and his kidneys began to fail. He was put on dialysis and set up with a dialysis clinic to see to his needs. Since he was homeless, he was often unable to find a way to get to treatments. Soon the dialysis clinic discharged him because he was “noncompliant”. He began to sporadically go into the Emergency room when things would get so bad that he could not stand it anymore. Soon the doctors and nurses in the emergency room knew him well. He figured out how to “work the system” for free meals and beds. He would go into the hospital, be stabilized and then back to the street.

At 28 years old John is homeless and using the emergency room to treat any health needs. He has uncontrolled diabetes, uncontrolled bipolar disorder and is in kidney failure. He has also lost the use of one of his hands and is in danger of losing several toes. He sleeps on the streets because there are no shelters he can stay in, and he can only eat when he is given a couple of dollars begging or when he is in the hospital. With no address he cannot get insurance so he cannot pay his hospital bills. Therefore, taxpayers are paying thousands of dollars a month to keep him in health care through the emergency room.

This story is completely fictional but is based on many true stories of homeless individuals across the country. It is a true commentary on the state of health care and homelessness in America. Individuals and Families across the country are thrust into homelessness for millions of different reasons and their healthcare is precarious as best. It continues to cost taxpayers millions of dollars to keep this population healthy through the emergency room when it costs a lot less to find ways to house and find safe shelter for them to sleep.

Statistics

The US Department of Health and Human Services puts homelessness at “582,462 people were experiencing homelessness across America. This amounts to roughly 18 out of every 10,000 people. The vast majority (72 percent) were individual adults, but a notable share (28 percent) were people living in families with children (National Alliance to End Homelessness, 2023).” The graphics below show a difference from the year 2015 to the year 2022 in who is experiencing homelessness. It shows that overall homelessness has increased with the majority increase in individuals and a decrease in homelessness experienced by families. The chronically homeless have increased whereas homeless veterans and unaccompanied youth have decreased. It shows that America has a problem with homeless individuals that contributes to the overall population health of the country.

    Graphics from State of Homelessness: 2023 Edition - endhomelessness.org

Public Health Implications

•  Homeless individuals and families have higher levels of health care need:

o   According to Stafford and Wood in “Tackling Health Disparities for People Who Are Homeless? Start with Social Determinants” since homeless people do not often have preventive care available to them and cannot afford healthcare, they will come into the emergency room when they absolutely cannot wait to get healthcare any longer (2017). Since this is the case their level of need is higher and thus the expense of the healthcare is much higher.

• Homeless individuals and families cost the health care system:

o   According to Greendoors, an organization that is concerned with helping the homeless in central Texas, “Nearly one-third of all visits to the emergency room are made by people struggling with chronic homelessness (Green Doors, 2023)”. They also estimate healthcare costs to be between 19,000 and 45,000 dollars a year. This is a cost that is absorbed by taxpayers since those who are homeless are not able to pay for their care. (Green Doors, 2023)

• Permanent housing lowers health care costs:

o   Health care costs are reduced by nearly 60% when a person finds a permanent place to sleep. (Green Doors, 2023)

Health IT/Data implications

• Public Health Departments need to have updated Health IT to have the ability to keep accurate health information for homeless individuals and families in the areas they serve. Between the public health department and the hospitals preventive services can be provided, but more consistent records are needed. (HealthIT.gov, 2023)

• An article in Digital Health by Alexia Polillo, Sophia Gran-Ruaz, John Sylvestre, and Nick Kerman, brings up the possibility of e-health services for homeless individuals and families so that they can be provided consistent medical care (Polillo et al., 2023). One issue with homelessness is that people are often moving from location to location without a consistent way to find preventive health services. E-health services might be a way to help these people find healthcare that is consistent. According to the authors more research is needed to determine the effectiveness of this option.

• Significant data is needed to determine the greatest areas of need and what is needed. More consistent records of homeless individuals from the time of first becoming homeless to follow-up after finding shelter is needed for conclusive research to be done. According to an article in the Lancet the longest follow up study was 6 years. A greater amount of data needs to be collected to do more consistent research. (Wickham, 2020).

Potential solutions

• Several hotels in Chicago were transformed into homeless shelters to great success during the past few years as concerns over COVID19 spread among the homeless population. (Johnson, 2021) In an effort to find temporary housing for individuals and families who are homeless, repurpose abandoned motels to make them into homeless temporary housing. In these living spaces, providing medical professionals who can provide preventive care and can provide mental healthcare services have helped improve the health of this population significantly. At the same time social workers can help those living there find jobs and permanent housing. (National Alliance to End Homelessness, 2023).
• A model for providing sleeping spaces for homeless individuals and families can be found in Springfield, MO. The model is called Eden Villages. These are small houses built for people who have been chronically homeless and/or have serious physical or mental handicaps that mean they have a greater need. The homes are built by volunteers and are communities where specific rules to be followed are required to live there. There is a small amount of rent that is required, and preventive medical services are available via donations from local churches and nonprofits (Eden Village, 2023).
• Another model in Sacramento County California are small sleeping buildings in an encampment where homeless individuals and families are given a clean and healthy place to stay for up to 90 days while they seek more permanent housing. There are clean communal areas and bathrooms with individual private sleeping areas. These people are chosen based on applications sent into a local nonprofit. They are given healthcare and other services to help them develop a better future. (Muegge, 2023)

Conclusions

          Homelessness is an epidemic in the United States that continues to get worse. Immediate interventions are needed to change the lives of homeless individuals and families. Still more interventions are needed to create change in the system before the individuals and families become homeless. Data is needed to conduct more research and create more interventions. Health IT can help to collect this data and to keep track of health records to improve the healthcare of those who are homeless. Collected data can help to pinpoint those who might be in need so that interventions can be made before someone loses their place of living. The combination of local governments, public health departments, and hospitals can intervene to help this population and, in the process, help to bring preventive healthcare to more people, save lives and ultimately save money for the taxpayers.

 

Eden Village. (2023). Imagine a city where no one sleeps outside. Eden Village: Tiny Home Communities for the Chronically Homeless. https://edenvillageusa.org/

Green Doors. (2023). The cost of homelessness facts. Homes Through Community Partnership. https://greendoors.org/facts/cost.php

HealthIT.gov. (2023, May 16). Public health. HealthIT.gov. https://www.healthit.gov/topic/health-it-health-care-settings/public-health#:~:text=Through%20the%20use%20of%20advanced%20technical%20solutions%2C%20public,essential%20to%20improving%20community%20and%20population%20health%20outcomes

Johnson, C. (2021, April 19). When homeless people lived in hotels, here’s what we learned. Chicago Tribune. https://www.chicagotribune.com/coronavirus/ct-prem-covid-19-homeless-shelters-hotels-20210419-3ihrct3rdvg65epnod6c2s5eru-story.html

Muegge, A. (2023, August 14). Sacramento County opens tiny homes for homeless. Here’s what the temporary shelter offers. https://www.sacbee.com/news/local/homeless/article278237088.html

National Alliance to End Homelessness. (2023, May 23). State of Homelessness: 2023 edition. Homelessness Data. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/

National Alliance to End Homelessness. (2023, May 23). Hotel to Housing Case Studies. Homelessness Data. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/

 

Polillo, A., Gran-Ruaz, S., Sylvestre, J., & Kerman, N. (2021). The use of eHealth interventions among persons experiencing homelessness: A systematic review. Digital Health, 7, 2055207620987066.

Stafford, A., & Wood, L. (2017). Tackling Health Disparities for People Who Are Homeless?             Start with Social Determinants. International Journal of Environmental Research and             Public Health, 14(12). https://doi.org/10.3390/ijerph14121535

Wickham, S. (2020). Effective interventions for homeless populations: the evidence remains           unclear. The Lancet Public Health, 5(6), e304–e305.