Managing Homeless Patients in the ED
February 1, 2024 5 minutes read
By Dorothy Brooks
It can be frustrating for emergency providers to care for patients who they know will have a hard time following through on prescribed treatments or directions because they lack access to housing. Yet, coming into contact with such patients is hardly a rare occurrence, particularly in busy urban settings. “When you’re taking care of your patients you want to be able to help them. That’s why you got into this field, and now there are so many times when you just find that you can’t actually help solve the problem that most of these folks are facing,” explains Kyle Stucker, MD, a third-year resident in emergency medicine at the University of Louisville School of Medicine.
This frustration and the fact that there is not much guidance to help emergency providers better manage this patient population prompted Stucker and several research colleagues to delve into the issue with a research project that they hope eventually will produce improvements in the way this patient population is managed in the ED. They discussed their efforts during a session at the annual convention of the American College of Emergency Physicians in Philadelphia in October 2023. The researchers surveyed ED nurses, physicians, and staff members with a range of questions that touched on general knowledge about the healthcare needs of homeless individuals and biases toward this population that the participants may have observed in the emergency setting, shares Stucker. “Then we took all of that data and we combined it with interview data that we obtained from members of the stakeholder community involved with the Coalition for Homelessness in Louisville,” he says The coalition includes an array of groups that provide care and services to homeless individuals in the region. Stucker adds that the researchers also included information gleaned from interviews with people involved in local politics.
“We brought all of this information together into a data set that we presented at a public deliberation,” says Stucker. “The point of this deliberative process was to take people with a diverse set of backgrounds and experiences, and then get them into a room talking together … to get a diversified set of solutions.”
Nurses, physicians, hospital administrators, and representatives from the local organizations focused on homelessness were included in the discussions. Stucker tells EDM it became clear that there was a lack of education among healthcare providers about how to connect homeless individuals with community resources that are actually abundant in Louisville. “If people keep coming to the hospital for aid and treatment, then that would be a great place to help get people plugged in so that they can actually access those services,” states Stucker.
The survey results showed that while 82.2% of the respondents said they felt confident in their ability to identify a patient experiencing homelessness, only 37.8% felt confident in their ability to educate patients experiencing homelessness on post-care including follow-up care, and just 17.8% expressed confidence in their ability to provide housing resources.
Another big issue is the significant role that bias plays in the care of homeless individuals. “About 65% of the emergency department participants felt like they had witnessed stigma in the care of homeless individuals while they were at work, but only about 40% felt like they were the source of any of this stigma,” shared Stucker. “There may have been some selection bias there because these were people who were willing to take this survey, so maybe they were a little bit more invested in the problem than the average person would be, but still those numbers don’t really add up.”
Stigma can impact the care of homeless individuals in multiple ways, explains Stucker. For example, it is not uncommon for homeless individuals to present to the ED with essentially fake complaints. This is frustrating to emergency staff, who then may start to assume that other homeless individuals are being dishonest about their symptoms. “The stigma that the providers [develop] from caring for [patients who present with fake complaints] can get transferred on to other individuals who may resemble them or have a similar socioeconomic status,” he says. The patients may receive less than optimal care as a result of such assumptions, notes Stucker.
Although there is a huge prevalence of drug use and mental health issues in the homeless community, that is not always the case, explains Stucker. When such assumptions are made, healthcare workers may exhibit a lack of empathy toward homeless individuals and may be less motivated to fully address chief medical complaints, explains Stucker.
The majority of survey respondents (88.9%) agreed that treating patients with homelessness is an area that the field of emergency medicine can improve. Armed with the knowledge gained from the survey results and discussions with stakeholders, the researchers are now planning their next steps. “We already have a packet that gets delivered to homeless patients in the emergency department,” explains Stucker. “It is a big list of resources, but the problem for a lot of these people is they don’t really have access to phones, so that is a barrier to using the current packet that they have.”
Consequently, the researchers are planning to develop a resource packet that healthcare providers can use to better manage patients with housing or other social needs. For instance, it will include a list of suggested questions that providers should ask patients about their needs. Based on the answers to these questions, there will be resources the providers can share with the patients. “This way we can make sure that we are identifying where there are gaps [in patient needs] … and then we can get patients pointed toward where they can get help to solve those problems,” he says.
The idea is to distribute the resource packet to healthcare providers within the hospital, see what results are achieved from this effort, and then, if it does well in terms of delivering benefits and value, distribute the resource packet to other hospitals in the region, explains Stucker.
Stucker advises emergency medicine colleagues to ask patients if they need anything else before being discharged. Stick to the basics, he says, asking them if they have a place to stay, weather-appropriate clothing, and enough food to eat. “Then I would encourage people to know the location of a few different places that are close to the hospital that you can at least point individuals toward to address a few specific needs,” says Stucker. “A lot of times, you may not know the answer to how you’re going to improve their lives, but by just asking the questions, there is certainly a chance that you could help them. I think that’s a worthwhile thing to do for them before they end up having to either get admitted to the hospital or to return to the ED after they were discharged.”
It can be frustrating to emergency providers to care for patients who they know will have a hard time following through on prescribed treatments or directions because they lack access to housing. Yet, coming into contact with such patients is hardly a rare occurrence, particularly in busy urban settings.
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