At last month’s State of the Homeless address, Cindy Crain, the outgoing president and CEO of the Metro Dallas Homeless Alliance, confirmed one of the demographic trends that has worried her the most: The homeless in Dallas are getting older and sicker.
A recent report from MDHA shows that a large percentage of the city's unsheltered homeless population is 55 years or older – and this age bracket is growing faster than others.
“The greatest impact of an aging homeless population is health care,” said Crain.
Nearly all of the homeless individuals in the homeless alliance’s database have been to a Dallas hospital in the past two years – and 35 percent of them were actually admitted.
“What's important about that is that they went to a hospital for conditions that didn’t require hospital care but probably a general practitioner or other type of health care,” Crain said to a group of homeless service providers and advocates. “But their practice and their habit is to go to maybe one of the most expensive delivery systems.”
Caring for 'High-utilizers'
Half of the homeless patients who went to the ER ended up going back at least three or more times in a year, and more than a quarter were readmitted three or more times in a year – sometimes even in one month.
These patients are who health care providers call the “high-utilizers,” and they visit emergency departments for anything from actual health emergencies (like a stroke or heart attack) to chronic disease maintenance to medication refills or even a cough. To add to that, many people experiencing homelessness age faster, with some in their 40s and 50s exhibiting health problems you’d usually see in people in their 70s or 80s.
“Sometimes people show up in the emergency department because they don’t have a primary care physician and they haven’t been accessing primary care for their adult life, so they wait until a crisis arises and they go to the emergency room. That’s what they know,” said Dr. Lara Johnson, a staff physician with Parkland’s Homeless Outreach Medical Services.
The HOMES program provides mobile health care to homeless patients to prevent costly trips to the hospital. Parkland’s emergency department sees about 30 to 40 high-utilizers a month. Nearly all of them are homeless and over the age of 50 with little to no health insurance – and in the past year, some had accumulated over $100,000 in unpaid bills. According to the Kaiser Family Foundation, patients like this represent just 5 percent of the U.S. population but account for half of all health care spending. The weight of high-utilizers is becoming too much for hospitals to bear.
“What we’ll see is continued overburdening of hospital ERs across the nation and more so than that, we’re going to continue to see negative health outcomes for these individuals,” said Sheryl Abraham is a “complex case” social worker at Parkland.
Addressing non-medical needs
Abraham is part of a program that’s designed to fill the gaps that doctors simply can’t. She prioritizes holistic care – connecting the homeless to closer, more appropriate medical services, asking more questions and better understanding their lives and their needs outside the hospital doors. In Dallas, the homeless are four times more likely to be a high-utilizer of the emergency department compared to other emergency department patients. Abraham recalls one such example: a patient diagnosed with paranoid schizophrenia, who had visited Dallas-area hospitals more than 200 times in two year.
“The anxiety that comes from [paranoid schizophrenia] prevented her from accessing an emergency shelter, so what she would do was she learned the cycle of ‘you can access an ER and you have to get seen,’ and she’d do that for years,” Abraham said. “We were able to work with CitySquare, their cottages program, and we were able to facilitate her getting a cottage. Since that time she has not returned to the ER.”
That has brought down costs for both Parkland and taxpayers, who ultimately foot the bill for the county hospital. Abraham said that woman’s experience is what being a social worker is all about: getting to the root of the problem, which isn’t always medical.
“Because typically for a patient that’s coming in multiple times for different primary complaints of foot pain, chest pain or whatever it might be, what we’ve found is that when we build the relationships, have that rapport with them and ask the deeper questions, they often do build the trust to reveal what is actually going on besides pain in their foot.”
If homeless individuals are coming to the hospital because they’re hungry, Abraham will find nearby food pantries. If they need substance abuse or mental health treatment, she might reach out to MetroCare services. And if they’re looking for a place to sleep at night – which they often are – she’ll help them get into shelters like the Bridge and Austin Street, or help them secure permanent housing with organizations like CitySquare. Approaching homeless, high-utilizing patients like this is saving Parkland a lot of money – and it’s building trust between the homeless and the medical community.
“I think where health care is headed is that we’re not able to just pay attention to the medical aspects of a person anymore,” Abraham said. “These types of patients, their needs at this high of a level or at a moderate level, are going to continue until the whole of a person is addressed.”
But social workers and doctors know there’s only so much even they can do for their homeless patients. Parkland’s Dr. Lara Johnson said it’s housing that truly makes the difference.
“I saw a patient this past week who is 65 years old, and he’s diabetic and has high blood pressure, and he’s now in housing,” Johnson said. “He has the resources to be able to make it on time to get his medications. He has food in his own home that he can prepare. He looked and felt so much better than I had seen him look and feel in months.”
For a rapidly aging homeless population dealing with the increasing pressures of instability and illness, an emergency room looks like a safe place -- a roof over their head. But with help from doctors, social workers and homeless advocates, an actual home can be a place for healing.
Outgoing Metro Dallas Homeless Alliance President and CEO Cindy Crain, who appeared at the top of the story, is a member of KERA’s Community Advisory Board.