Tackling Health Disparities for People Who Are Homeless? Start with Social Determinants

Abstract

Background: Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. Aggregated health service data can mask this, and case histories thus provide important insights. Methods: This paper presents three case histories of homeless patients seen at an inner city public hospital in Perth, Western Australia. The case histories draw on several data sources: hospital data, information collected from rough sleepers and clinical observations. Estimates of the cost to the health system of the observed hospital usage by the three patients are included. Findings: The case histories illustrate the interplay of social determinants of health in homelessness that help explain the high level of hospital usage by rough sleepers. The cumulative healthcare costs for the three individuals over a 33 months period were substantial. Hospital attendance plummeted even in the short term when housing needs were addressed. Conclusions: Treating homelessness as a combined health and social issue is critical to improving the abysmal health outcomes of people experiencing homelessness. In addition, the enormous economic costs of hospital care for people who are homeless can be reduced when housing and other social determinants are taken into account.

Homeless health care: meeting the challenges of providing primary care

“…At the core of the poor health of people who are homeless is the absence of a safe and secure house in which to live. As Stafford and Wood observe: “Addressing homelessness is, itself, an important form of health care, not a separate ‘non‐health’ issue” 20 . Studies internationally and in Australia demonstrate significant reductions in ED presentations and inpatient length of stay when housing is coupled with wrap‐around support for homeless individuals 20 , 26 , 27 .…”

“…As Stafford and Wood observe: “Addressing homelessness is, itself, an important form of health care, not a separate ‘non‐health’ issue” 20 . Studies internationally and in Australia demonstrate significant reductions in ED presentations and inpatient length of stay when housing is coupled with wrap‐around support for homeless individuals 20 , 26 , 27 . Lengthy admissions for psychiatric care or mental health problems have been shown to reduce when supportive housing is provided to people who were homeless 20 , 28 …”

“…18 In many EDs across Australia, people who are homeless are among the most frequent presenters, unplanned admissions are high, and length of stay is longer. [19][20][21] This is a preventable cost to the health system; in the first 8 months of 2017 alone, around 30% (900) of our Homeless Healthcare clients accounted for 3135 presentations to Royal Perth Hospital ED, equating to an estimated cost of $2.4 million (based on an average presentation cost of $765). 22…”

“…20 Studies internationally and in Australia demonstrate significant reductions in ED presentations and inpatient length of stay when housing is coupled with wrap-around support for homeless individuals. 20,26,27 Lengthy admissions for psychiatric care or mental health problems have been shown to reduce when supportive housing is provided to people who were homeless. 20,28 Housing First, a model originating in New York, is premised on the philosophy that stable housing is an essential first step to addressing the complex medical and psycho-social issues faced by people experiencing homelessness.…”

“…20,26,27 Lengthy admissions for psychiatric care or mental health problems have been shown to reduce when supportive housing is provided to people who were homeless. 20,28 Housing First, a model originating in New York, is premised on the philosophy that stable housing is an essential first step to addressing the complex medical and psycho-social issues faced by people experiencing homelessness. 29 People are housed in permanent accommodation initially and then offered individualised support to help them maintain their tenancy and address issues that might otherwise see them return to homelessness.…”