Emergency room often easiest route for homeless health care
But it’s also ‘a very inefficient way to deliver care,’ says one researcher
For many homeless people, the easiest place to turn for health care is often the emergency room, said Carol Petith-Zbiciak, doctor of nursing practice at the University of Hawaii Maui College.
The care is quick and guaranteed. But it’s costly for both hospital and patient, and many of the ailments that require urgent attention can be prevented through earlier care.
“That’s the default place to go,” Petith-Zbiciak said. “But it’s a very inefficient way to deliver care.”
Connecting the homeless to better health care is Petith-Zbiciak’s goal. Recently, the registered nurse and college professor did a study to find the unmet health care needs of Maui’s homeless.
More than 564,000 people in the U.S. experienced homelessness on a given night in 2015, and Hawaii had the highest per capita rate of homeless people of any state in the nation, according to National Alliance to End Homelessness statistics cited in the study. On one night in January 2016 on Maui, 1,145 homeless people were identified during a point-in-time count, 58 percent of whom were unsheltered. Since 2012, the number of homeless on Maui has increased by 31 percent.
While working at the college, Petith-Zbiciak saw “evidence of a lot of unmet needs” of homeless people in the community. Every other year, the college would hold a one-day clinic, and nursing students would help care for anyone who stopped by.
“When we tried to refer people, it was really hard because we couldn’t get them in anywhere except the emergency department,” Petith-Zbiciak said. “There were so many indications of people not getting their health care needs met and being in real poor health.”
So Petith-Zbiciak went looking for unsheltered homeless people to interview. Over the course of five months in 2015, she spoke with 32 of them over the age of 18, most of whom were unsheltered or staying at an overnight shelter. She also interviewed 12 people familiar with the health care needs of the homeless on Maui and a group of hospital social workers.
Stable housing, wound care, medication and dental care were among the top unmet needs among those she interviewed. And all of the interviewees had something in common.
“All 32 of the homeless people . . . had some kind of barrier to getting access to primary care services,” Petith-Zbiciak said.
For many, this barrier was a lack of identification or health insurance, she said. Without a place to store their personal documents, many had either lost these important papers or been robbed. Setting up appointments and qualifying for discounted care was difficult without documents.
For those who could get appointments, some found it difficult to meet them, due to a lack of transportation or ways to keep a schedule.
“Not every one of them can pull together their schedule in their lives because they’re so busy seeking shelter,” said Helene Cannella, member services director with Malama I Ke Ola Health Center. “By the time these individuals get the medical help that they need, they’re in such dire straits that they’ve got to go to the ER.”
Malama I Ke Ola Health Center, a federally qualified health center, was opened to meet the need for health services “for the homeless, poor and underserved,” according to its website. It has locations in Wailuku and Lahaina.
Both Cannella and Petith-Zbiciak said that homeless patients needed primary care to help prevent many easy-to-treat problems from becoming more severe. But some interviewees in the study said it was tough to get into Malama I Ke Ola Health Center, because they lacked documentation and couldn’t make appointments. A walk-in clinic would be helpful, they said.
While Malama I Ke Ola doesn’t have a full walk-in clinic, it does offer walk-in appointment slots “that are equal to five times the rate of the homeless population at our clinic — two each morning and two each afternoon per provider,” said B.J. Ott, the center’s chief financial officer and deputy director.
“We do what we can within the requirements of the limited federal funding we receive, which does not include homeless funds, nor are homeless funds available to us at this time,” Ott said. “A quick estimate of the cost to provide a dedicated walk-in clinic per year is $750,000.”
Cannella said that the federally qualified health center accepts patients even if they don’t have documentation. After patients receive care, her department works with them to get an ID. Sometimes they’ll try to contact family or look for online records in a person’s home state.
“There’s always a way,” she said.
The office also screens and enrolls every uninsured patient who comes through the clinic. Even if someone doesn’t have documents to qualify for discounted care, there are other options, Cannella said. If he or she can pay on the day care’s received, there’s a 50 percent discount. If not, the full fee is charged, although patients pay whatever they can provide. Over time, patients repay the clinic “whatever they can until their bill is done.”
Maude Cumming, executive director at the Family Life Center in Kahului, said that her organization focuses on getting people to housing first, “then surrounding a person with support services.” Cumming and her staff stay with people every step of the way — driving them to appointments, bringing them medication, helping them sign up for insurance.
“It’s continual follow up and hand holding until they can stabilize,” Cumming said. “It’s a lot to stabilize somebody that has been homeless for a while.”
Cumming said “somewhere along the line there’s a disconnect,” and government, law enforcement, health providers and agencies that work with homeless people need to work together better to help stabilize homeless individuals.
But she’s hopeful, given new state contracts that allow agencies like the Family Life Center to continue assisting a person once they’ve been housed.
“Our goal is to ensure that when a person gets housed, it is housing forever,” Cumming said.
Cannella said one of the biggest issues surrounding health care and the homeless is the stigma.
“If we can really address the stigma, I think we’re halfway there,” Cannella said. “Homeless people are not necessarily homeless because they choose to be.”
As health care providers, “it’s not our job to figure out why you’re homeless,” Cannella said. “Our job is to figure out how we can help you while you’re homeless.”
Many people in her study agreed the stigma was a “barrier,” Petith-Zbiciak said. She suggested training for both providers and patients that would help doctors give care “in order not to cause further trauma,” and coach homeless patients about “attitudes and behaviors consistent with accessing health care services.”
“I think it’s possible to help people in a way that doesn’t always require multiple millions of dollars,” Petith-Zbiciak said. “Sometimes people are so sick they’re not able to really even think about jobs and education.”
* Colleen Uechi can be reached at email@example.com.