In 2019, about 567,715 homeless people lived in the United States. While this number had been steadily declining since 2007, in the last two years it has started to increase.
For New York City, even before COVID-19, 2020 was already turning out to be a record year for the homeless. But when the shutdown began in mid-March, the 60,923 homeless people staying in the city’s shelter system were disproportionately affected by the pandemic.
That is not all for these people, of course; the more than 60,000 do not include homeless people hiding within emergency department waiting rooms and patient lists. In 2019, the annual count of homeless people in the city shows more than 300 for any given night who happen to be patients or who use the hospital as a temporary shelter.
As a healthcare professional, educator, and researcher in the field of public health and social epidemiology working in the city, I am fully aware of the challenges faced and the tragedies that have already been seen.
As of May 31, the New York Department of Homeless Services had reported 926 confirmed cases of COVID-19 in 179 places of refuge and 86 confirmed deaths from COVID-19. In April alone, DHS reported 58 homeless deaths from COVID-19, 1.6 times the city’s overall rate.
While there are no reliable analog data for other cities, what happens in New York may be a lesson to others.
Homeless shelters are vulnerable
The homeless population’s susceptibility to COVID-19 is not unique to New York City. Homeless shelters almost everywhere are particularly vulnerable to disease transmission. Shelters are generally ill-equipped, heavily trafficked, and unable to provide safe care, particularly for people recovering from surgery, injury or illness.
Added to this is the inability to isolate, quarantine, or physically distance the homeless from each other during COVID-19. New York responded by using nearly 20 percent of its hotels as temporary shelters, with one or two customers per room. That helped, but it wasn’t a perfect situation.
So the question is: Where do homeless patients go to convalesce when they are discharged from acute medical care, especially in the post-COVID-19 era?
Homeless patients discharged from hospitals or clinics who then go to drop-in centers, shelters, or on the street sometimes do not fully recover from their illnesses. Some inevitably return to the hospital. The result is a harmful and costly cycle for both patients and the healthcare system.
And the situation continues to deteriorate: Between July 2018 and June 2019, 404 homeless people in the city died – 40 percent more than the previous year and the largest year-on-year increase in a decade. There is no data since the outbreak began, but early evidence suggests that the death toll is highest between June 2019 and June 2020.
Medical Relief: A Possible Solution
Medical relief is short-term residential care for the homeless who are too sick or frail to recover on the streets, but not sick enough to be in a hospital. Provides a safe environment to recover and continue to have access to post-treatment care management and other social services. Temporary medical care can be offered in freestanding facilities, homeless shelters, nursing homes, and transitional housing.
Medical relief has worked in municipalities across the United States; patient health outcomes have improved, and hospitals and insurance providers, particularly Medicaid, have saved money. But these programs are few and far between. In 2016 there were 78 programs operating in 28 states. Most of the programs are small, with 45 percent having fewer than 20 beds.
Models of care vary, but essentially provide beds in a space designed for convalescence, support for follow-up appointments, medication management, medically appropriate meals, and access to social services such as home navigation and benefits assistance. Some programs provide on-site clinical care.
Research shows that homeless patients in New York City stay in the hospital 36 percent longer and carry an average cost of $ 2,414 more per stay than those with stable housing. By discharging patients to respite programs, hospitals reduced post-discharge emergency visits by 45 percent and readmissions by 35 percent. The New York Legal Aid Group, which conducted a cost-benefit analysis, found savings of nearly $ 3,000 per rest stay (provider saved $ 1,575, payers saved $ 1,254) thanks to the reduction of hospital readmissions and length of stay.
Studies outside of New York also show improved health outcomes in a number of ways. One noted that 78 percent of patients were discharged from the relief program with « improved health. » Patients showed increases of 15 to 19 percent relative to primary care after discharge. On the other hand, at least 10 percent and up to 55 percent of discharged medical respite patients eventually transitioned to permanent or improved housing situations.
While there are agreed national standards for medical relief, program models can be tailored to meet the needs of a specific community. There are already dozens of models of relief throughout the country, in both large cities and small towns. One complication, however, is the breadth of focus. Because it intersects housing, homelessness and health care, medical relief does not fit neatly into a single system and would require collaboration and agreement between multiple city and state agencies.
However, a growing number of communities are seeking relief to fill the void. Chicago partners with providers to provide health care for the homeless. This includes providing them with temporary residential and clinical facilities to help mitigate the impact of COVID-19.
There is a great need to help the homeless with housing and health care. Relief is a potential solution. It has successfully provided housing and medical care during a pandemic. Why shouldn’t it become a permanent part of our service system?
You can find the original text in the following link:
J. Robin Moon is Adjunct Associate Professor at the City University of New York.