INTRODUCTION/ BACKGROUND
The issue of poor health among the homeless is a national crisis. In combination with access to healthcare, social determinants affect much of one’s health quality. These can include personal identifying factors such as race and age but can also be shaped by secondary elements like housing, income, education level, and opportunities. With homelessness, these secondary factors can be very low quality and contribute to poor health.
This issue is tangible and of importance to a large demographic. According to the 2016 U.S. Department of Housing and Urban Development (HUD) Annual Homeless Assessment Report, approximately 549,928 people were homeless on a single night during that year, and 32% of those people were not sheltered.1 The homeless population is more likely to experience health issues than other groups, with a 1.5 to 11.5 times higher risk of mortality than the rest of the population.2 Homeless individuals pass away on average, 12 years earlier than the rest of the general population.3 They also disproportionately experience issues like the inability to access care and prescriptions, and have higher rates of disabilities, mental illnesses, and substance abuse, among other health issues.4 In 2017, HUD reported that individuals living in shelters are over twice as likely to have a disability when compared with the rest of the population.5 Also, in 2017, “20 percent of the homeless population reported having a serious mental illness, 16 percent conditions related to chronic substance abuse, and more than 10,000 people had HIV/AIDS.”6 Below is figure 1 from the Health Center Patient Survey (HCPS) done by the Health Resources and Services Administration, a branch of the federal government, in 2009. Figure 1 gives a general overview of the differences in health between the U.S. homeless population and the U.S. general population.
Figure 1. Health conditions among housed and homeless populations in the United States. (Source: Health Center Patient Survey (HCPS) 2009).
As evidence by the data in figure 1, the homeless population experiences disease and chronic illness at an alarmingly higher rate than the general population; for example, the homeless population is twice as likely to suffer from diabetes and 20 times more likely to suffer from HIV (HCPS).7 Several reasons for this are listed below:
- The act of living in a shelter,
- Lack of access to high-quality, nutritious food,
- Constant exposure to weather conditions,
- Exacerbation of physical and mental health issues as a result of living on the street.8
Simply the act of living in a shelter or on the street is a health risk. In these environments, individuals are more likely to be exposed to diseases including tuberculosis, flu, and more.9 They are also more likely to experience malnutrition and/or hunger; the low income that generally accompanies homelessness means that there isn’t a lot of money to spend on high-quality food. Affordable meals in fast-food joints or shelter kitchens generally consist of high-calorie, filling foods meant to provide basic sustenance but not nutrition.10 Further, being without housing and receiving low income, weather conditions pose severe risks to health, as individuals potentially lack income/means to purchase shoes, warm clothing, and other necessities, taking an additional toll on the body and health. Physical chronic conditions are generally made worse by lack of proper storage for medication, and mental health and substance abuse are similarly aggravated by trauma on the streets, as well as bleak outlooks on the part of homeless individuals about the future.11 When homeless individuals become injured, their wounds are less likely to heal quickly, fully, or properly when they don’t have access to basic first aid or hygiene to keep the wounds clean.12 As draining as this list may seem, it is nowhere near exhaustive of all the detrimental effects homelessness has on health.
There has been a significant amount of research done on homelessness as a social determinant of health, with different studies examining smaller sectors of the homeless population based on other identifying factors. Similarly, there have been many proposed plans aimed at helping homeless populations and boosting their quality of health.
In this literature review, I am comparing and contrasting some of these approaches. Current research identifies a wide variety of plans addressing homelessness as a social determinant of health, whether it be through improving housing, the patient care system specifically for homeless patients, or another implementation. Although there is research on the varying degrees of success for different methods, the field lacks a comprehensive, comparative review of the main interventions. As such, my literature review will aim to answer the question: which, if any, of the different interventions targeting mitigation of homelessness as a social determinant of health reduce hospitalization and emergency room visits among homeless adults? I intend to compare the studies through these categories: type of intervention, control (if any), outcomes, and results. Although each study will have results specific to its own research question, the research examined will all be comparable in the sense that every plan aims to reduce emergency department and/or hospitalization visits, and each somehow addresses one or more aspects of homelessness as a social determinant of health.
This literature review is important for establishing a foundation as to which approaches are more effective in mitigating the negative effects of homelessness on health. As this country grapples with the issue of homelessness (in addition to much broader root-cause issues of wealth inequality, lack of adequate access to healthcare for the entire population, etc.), it is crucial for policymakers to understand how to best approach the issue of homeless health. In addition, homelessness is an issue that affects a sector of the population that is most often neglected and has very little political capital to leverage for better living and health conditions. As such, it is doubly important that this literature review serves as a mechanism to draw attention to the dire nature of the issue and present policymakers with a clear guideline for future action that cannot be ignored.
METHODOLOGY
This research paper is in the form of a systematic literature review. To obtain the research for this systematic review, I first used the search engine PubMed. In the search engine, I looked up “homeless” as a MeSH term and “hospitalization” as a MeSH term. I then narrowed down my search by adding filters. I first used filters that would make it easier logistically for me to read the articles; specifically, I narrowed it down to papers that were available in English and in full text. Then, I narrowed my search down by type of study, looking only at clinical studies and comparative studies. I also narrowed the studies down by age group, only looking at clinical and comparative studies done about adults (19+ years old). Finally, I narrowed the search by year, exclusively looking at studies done after the year 2000. I chose to look at more current research because I wanted my systematic review to reflect the most up-to-date research and knowledge in the field, and I felt that a 20-year margin would sufficiently yield a breadth of research while keeping the research relevant. With these different filters, the search engine yielded 49 results. However, many were still not relevant to my research question. I decided to manually read through the results and find research that applied to my question. I automatically discarded papers that did not have some type of intervention. I also automatically discarded papers that were not focused on a homeless population. I used my judgment to sort through the rest of the results; for example, a controlled smoking trial was irrelevant, but a study on the continuity of care to prevent rehospitalization among the homeless was relevant.
DISCUSSION
Analysis of Results
This literature review looks at multiple different forms of intervention to determine which, if any, were the most successful in lowering emergency department (ED) visits and hospitalization rates among homeless individuals.
There were several studies that used a form of housing as their intervention (Kerman et al., Kessell et al., Sadowski et al., and Srebnik, Connor, and Sylla). Overall, ED visits were decreased with housing as the intervention. However, the data showed that although there were reductions in ED visits, those reductions were also seen in three of the four studies’ respective control groups (Kerman et al., Kessell et al., and Srebnik, Connor, and Sylla). This raises the question of causation for the housing programs; did the respective interventions lead to the decline in ED visits or not? Reductions in hospitalization rates had a similar trend; they occurred across all four studies, two of which had no difference when compared with the control group. The transitional housing after hospital discharge followed by long-term housing with case management (Sadowski et al.) was the most effective at reducing hospitalizations and ED visits out of the four in comparison to the control. Overall, housing as an intervention seems to reduce ED visits and hospitalizations, but it remains unclear how causational the relationship is, seeing as control groups from four different studies overall experienced similar reductions in ED visits and hospitalizations.
Changing the type of patient care was an intervention used by several studies reviewed in this paper. Specifically, enhanced hospital care (Hewett et al.), medical homes and patient-aligned care teams (O’Toole, Johnson et al.), population-tailored primary care (O’Toole, Buckle et al.), and outpatient follow-up (Currie et al.) were examined. Altering patient care is a broad spectrum and has numerous possible implementations; as such, various results were yielded. Neither outpatient follow-up nor enhanced hospital care had significant decreases in ED visits and/or rehospitalization rates. However, the interventions of population-tailored primary care and medical homes & patient-aligned care teams overall had significant reductions in ED visits and hospitalization rates. There is a clear difference in the interventions that successfully reduced ED & hospitalization rates and those that did not. Both outpatient follow-up and enhanced hospital care are interventions that take place once an individual has already been admitted to the hospital. In comparison, the other two interventions in this category were primary care interventions and took place before any hospitalizations. This leads to the inference that preventative, consistent primary care is more effective at reducing hospitalization rates and ED visits, whereas interventions that occur after admittance to the hospital are less effective. This could be due to several reasons; perhaps the lack of long-term continuity of care weakens the effectiveness of these interventions, or perhaps by the time that patients enter the hospital, they are already injured or ill in some way, and it is more difficult to care for them than if the injury or illness had been prevented altogether with one of the preventative primary care interventions.
Weaknesses
There are several weaknesses within the methodology of the systematic literature review. First, the literature review relies solely on the PubMed database, when there are plenty of additional studies done that are published elsewhere and were missed since they were not found on PubMed. Additionally, the combination of key search terms and filters was not perfect; there were numerous articles that fit under the search input but were still irrelevant to the research question. Thus, I had to manually go through every single result and verify whether or not it would be usable, which not only was incredibly time consuming, but also makes it more difficult for an independent researcher to replicate, as one could argue that choosing research papers fit for the research question out of the 49 search results is somewhat subjective.
There were also some limitations to the analysis of the effectiveness of the interventions. This literature review only looked at the outcomes specifically related to either hospitalization rates or ED visits. However, most of the studies had other outcomes, some which reflected quite positively on the success of those interventions in improving the health and/or quality of life for homeless individuals in their respective populations. In the discussion section, several of the interventions were highlighted as being ineffective for reducing ED visits and/or hospitalization rates; however, this does not necessarily imply that the implementation is useless overall. On the contrary, some had impressive results outside of the scope of this literature review and should not be overlooked or discarded due to their lack of or limited success within this stated scope. Comparison to Other Literature Reviews
An additional literature review similar to this one was done by Salhi et al. This literature review differs from that one in the sense that it is more recent: Salhi et al., examined research from 1990 to 2016. More importantly, their research found that homelessness is “under-recognized in the ED setting” and that the needs of homeless patients are not currently being met by the model of EDs.13 They conclude that “more research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.”14 This literature review aimed to answer the question of which treatment strategy works best, and thus fills in some of the gaps that Salhi et al., posed.
Policy Implications
Based on the results from this literature review, the most logical recommendation for policymakers is to create legislation that promotes primary care for homeless individuals. Primary care had, by far, the most success in reducing ED visits and hospitalization rates. Primary care also makes sense from a legislative standpoint because primary care is the most focused on prevention and as such, there are less likely to be hospitalizations/ED visits for injuries/illnesses that could have been prevented or treated at a very early stage. In the background section of this literature review, it was mentioned that homeless individuals tend to suffer from a variety of injuries such as foot problems due to lack of proper shoes/insulation and ailments caused by weather exposure.15 It was also mentioned that when homeless individuals become injured, their wounds are less likely to heal quickly, fully, or properly when they do not have access to basic first aid or hygiene to keep the wounds clean.16 With primary care interventions, many of these problems would be taken care of at earlier stages and would therefore be easier, less emergent, and less costly to treat. A cut, for example, would be easily bandaged up and would be able to heal properly, rather than becoming infected and causing a more serious illness. Not only would this improve the health of homeless individuals, but logically, it would also significantly reduce their cost of care. Although it is impossible to directly compare costs in this literature review as homeless individuals have a wide range of potential co-pays depending on their insurance or lack thereof, but it can be inferred that the cost of a check-up at a clinic specifically meant for homeless individuals (the assumption is that policymakers would make this free or very cheap for homeless individuals so that it remains affordable and accessible) is going to be significantly less expensive than a trip to the emergency room, with more tests and potentially nights in the ED depending on the severity of the ailment.
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