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The Social Determinants of Health: Homelessness and Unemployment

Yesterday, you visited the emergency room after experiencing intense abdominal pain. You were admitted for appendicitis and underwent an emergency appendectomy later that day. Once you were cleared for discharge, you received a bag of pain medications, instructions to keep your incision clean and dry, and told to avoid strenuous activities. Simple, right?

Unfortunately, for most homeless patients, this situation is anything but simple. What may seem like a standard outpatient surgery could in fact be the start of a long struggle with pain management, infections, and almost inevitable readmissions.

So how can providers break this cycle? Essential hospitals such as Santa Clara Valley Medical Center, Harborview Medical Center, and Hennepin County Medical Center are answering this question by offering patients tailored primary care, intervening in care transitions, and helping patients find stability through housing and employment.

Homelessness Is a Health Hazard  

Homelessness or unstable housing is a significant social determinant of health. Homeless patients may be predisposed to worse health outcomes due to poor living conditions and food insecurity. Additionally, these patients also tend to have limited resources for self-care. For example, a homeless patient with diabetes may have difficulty managing this condition without an appropriate place to store insulin and access to nutritious food.

Homeless patients may also reside in hard to reach places (e.g., heavily wooded areas) or be very transient and have little or no transportation. These access issues create challenges for health care providers in reaching homeless patients and establishing the patient-provider relationships necessary for effective treatment.

Providers Offer Patients a Medical Home

Homeless patients are often in desperate need of stable primary care services. The patient-centered medical home (PCMH) is a primary care model that may be well suited for homeless patients’ needs. For example, care teams and expanded access models may give patients an opportunity to be seen on short notice by a multidisciplinary team of providers.

Santa Clara Valley Medical Center offers an example of this care model with its Valley Homeless Healthcare Program (VHHP), which is a PCMH tailored to meet the needs of the local homeless population. All of the clinics operate on a walk-in only basis, which removes the need for patients to make an appointment in advance. Patients receive care from physicians, nurses, behavioral health providers, and social services team members. VHHP also operates a number of mobile and on-foot units in order to reach remote patient populations. Most importantly, the main VHHP clinic is located in the same building as the local shelter and medical respite program.

Medical Respite Aids Care Transitions

Medical respite programs are an effective tool for intervening in the posthospital transition that often leaves homeless patients at a disadvantage in their recovery. Instead of returning to the streets after discharge, patients have a safe and clean space for their recovery and self-care. Medical respite programs greatly reduce the cost of care for homeless patients and decrease readmissions.

Santa Clara’s medical respite program opened in 2008 and includes 20 beds where patients can recover after a hospital stay. The program is operated by VHHP, which provides medical staff onsite. A number of social resources are also available, including help connecting with a primary care site, applying for important social benefits, and finding permanent housing. Of patients who stay through the term of their recovery, 99 percent are placed into appropriate housing.

Harborview Medical Center in Seattle, Washington, also operates a large medical respite program in partnership with the Health Care for the Homeless Network. The program offers patients a full, round-the-clock medical team, including mental health providers.The team also works with patients to help provide social services, regular primary care, and housing. In 2011-2012, 83 percent of patients were discharged with direct links to a primary care site.

Employment Plays a Role in Stability

Unemployment tends to go hand-in-hand with homelessness and carries its own health disadvantages. Unemployed individuals are likely to self-report worse health status, may experience more depressive symptoms, and are at a higher risk for mortality.

While unemployment is not exclusive to homeless patients, it is a common issue associated with many other social determinants of health, such as food insecurity, poor social capital, and unstable housing. Stable employment can enable individuals to live healthier lives by residing in safer neighborhoods, affording better health care, providing education or child care for their children, and buying nutritious food. Thus, addressing unemployment can be an essential step to treating other significant social determinants of health, especially for homeless patients.

Hennepin Health, a patient-centered care program from Hennepin County Medical Center, works with low-income, complex patients to address their medical and social needs, including unemployment. Hennepin Health has partnered with a local organization, Rise, Inc., which offers patients the resources they need to seek and achieve employment. Hennepin Health and Rise also work to provide patients with appropriate housing in conjunction with finding employment, as increases in wages may displace patients from low-income housing. These efforts have not only resulted in numerous success stories, but have also decreased health care costs for program participants by 60.3 percent.

Treatment Must Go Beyond Medical Care

Housing and employment are two social determinants of health that work hand-in-hand and can significantly impact health outcomes. Addressing homeless and/or unemployed patients’ medical needs alone is not a sufficient course of treatment. Providers must treat the source of the problem by helping patients find stable housing and employment. Santa Clara’s VHHP, Harborview Medical Center, and Hennepin Health are three prime examples of the innovative work many essential hospitals have undertaken in this area. As homelessness and unemployment persist in our country, providers should look to these examples as they work to provide comprehensive care, improve health outcomes, and reduce health care costs. provides a resource for hospitals on the journey to community-integrated health care. Learn more about how our hospitals address social and economic factors that influence health, take a virtual tour of population health programs nationwide, and share a program of your own.

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About the Author

Janelle Schrag is a senior program analyst with America's Essential Hospitals.

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