The Danger of Discharging Patients to the Streets
Winters are particularly deadly for people experiencing homelessness. Hospitals are not the refuges they can be.
By Michelle Munyikwa
Image by Esther Moon.
“Where are you staying right now, sir?” I asked the man in front of me. He was leaning against the wall, one leg propped up on the hospital stretcher, one of many lining the hallways of our emergency department. I suspected that he was between houses, judging by the state of his clothes. Based on his chart, I knew he had been to several other emergency departments that week.
“Around,” he told me, both of us knowing it wouldn’t make a difference if he said what we both knew. As had happened each day that week, he would undergo a brief evaluation and be sent out into the street to find a place to sleep.
This winter, like every other which has preceded it, will leave healthcare workers in the difficult position of discharging some patients who have nowhere to go.
While exposure to the elements is a year round problem, winters are particularly deadly for people experiencing homelessness. As temperatures across the United States drop, the risks of exposure increase for the over half a million Americans who find themselves without shelter. At least 20 people experiencing homelessness die each day in the United States, but incomplete data sets and research challenges make it hard to know exactly how many people die each year from exposure to the elements. Estimates range from 5800 to upwards of 45,000. Deaths among the homeless have increased each year since 2016, likely a combination of untreated illness (including COVID-19), violence, and an increasingly lethal and unpredictable drug supply resulting in an uptick of overdoses. Extreme weather conditions also shape the death toll each winter.
How to prevent these deaths is an ongoing debate. Recently, New York City leadership has announced a plan to address this problem with the involuntary hospitalization of people with mental illness that struggle with housing. While this plan has flaws, the announcement and the conversation surrounding it have highlighted the role of hospitals, as institutions of care, in preventing the worst outcomes for those without shelter.
This winter, like every other which has preceded it, will leave healthcare workers in the difficult position of discharging some patients who have nowhere to go. While the law mandates that hospitals discharge patients to a place where they can access shelter and resources, for many patients that means a plan to go to a local housing agency, with no guarantees about when or how they will receive stable housing. Still others leave with a plan to obtain tenuous, temporary housing with family or friends, unsure of how long it will be until they overstay their welcome. Coupled with an ongoing housing crisis, the crunch on American hospitals means that this will likely be the worst winter in recent memory for those experiencing homelessness and housing instability.
Discharges to the street occur commonly in the Emergency Department, as people experiencing homelessness come in for concerns that are not strictly emergent, often seeking a warm and safe place to rest. Emergency providers I spoke with told me that with rising ED volumes, wait times, and increasing pressure to move patients quickly, unofficial practices of allowing overnight shelter in a room with a turkey sandwich and a blanket have given way to keeping patients in hallway beds or uncomfortable chairs. Once patients are admitted to the hospital, conditions within the hospital, including intermittent bed shortage, cause pressure to discharge patients as soon as possible.
However, in emergency departments, increased use of “fast track” sections, hallway beds, and uncomfortable situations serve almost as a deterrent for desperate people who might otherwise have a chance to sleep in a bed for a night. Intermittent waves of COVID seem to have shifted the culture around care for those experiencing homelessness. Provider discretion can, at times, lead to admission for patients who in theory could recover at home but require shelter for optimum recovery. Even once admitted, there are no guarantees that patients will be able to stay in the hospital until their precarious housing situations improve.
Outside of the hospital, an ongoing housing crisis threatens to make this situation worse. Many cities are seeing previously accessible affordable housing purchased and repurposed for luxury housing or other commercial purposes. In Philadelphia, where I work as a resident physician, the end of several housing subsidies threatens to eliminate even more of the city’s dwindling housing stock, leaving many families facing housing precarity as the winter looms ahead.
Ultimately, I discharged my patient from the emergency department that day. He didn’t meet admission criteria, even though I knew he would likely not improve while out of the hospital. Every provider I’ve spoken to has told me at least one similar story: they were conflicted about having to send someone out into the cold, knowing they had no place to go. Sometimes, they told me, they were able to work the system to help shelter their patients in the hospital, but more often than not, they found themselves handing discharge papers to someone who would spend the rest of the night seeking somewhere warm.
Housing is health care. It is thus imperative that as providers of health care, we attend to the foundational importance of stable shelter in the lives of our patients. Health systems have an important role to play in addressing the needs of people experiencing homelessness in their communities. While this obligation is often framed within the lens of cost-cutting for the overall health system, there is also an ethical obligation to the community, especially given the role of many health systems in increasing real estate costs in their local areas.
Both insurers and health systems have considered entering local housing markets in settings where affordable housing poses challenges for their patient populations. While this could be lauded as admirable, it is hard to applaud health systems for stepping in to solve problems which they have generated, and there are many problems with their involvement in these local markets. It is hard not to imagine that further entrenchment of health systems in their local real estate markets would not have disastrous unintended consequences.
That being said, the status quo is not enough. If nothing else, the early days of the COVID-19 pandemic showed that it is possible to produce shelter. Many cities developed temporary COVID hotels and shelters, where people with cases too mild for hospitalization but without a safe place to quarantine would stay. These shelters were plagued with problems, but they did offer some respite, and they most importantly demonstrate the capacity to address this problem.
At the very least, we need increased funding for social workers and case managers, who facilitate the safe placement of patients after hospitalization or discharge from the emergency department, and who are sorely overworked and underpaid in our current healthcare system. Others advocate for further embedding housing and other resources within healthcare systems, making hospitals one-stop shops for accessing both clinical and social services. Most importantly, we must address the root causes and push for health systems to participate in generating affordable housing and well-resourced communities, in part by paying taxes to their local communities and paying all of their employees a living wage.
Ultimately, health systems should be integral institutions of care in our communities. They could and should be a respite from the storm, not the force which casts people out into it.
Michelle Munyikwa is a resident physician in combined internal medicine and pediatrics at the Hospital of the University of Pennsylvania and Children's Hospital of Pennsylvania. Follow her on twitter at @mrmunyikwa.