Homelessness is a pervasive and debilitating problem in the United States, affecting the lives of over half a million individuals every year.
Despite reform efforts, the outdoor, unsheltered homeless population has surged over the previous decade, exceeding 250,000 in 2023.
Accessible housing initiatives have expanded but homelessness persists. The consequences of homelessness are especially prominent in healthcare, as populations without stable housing are more likely to experience a wide range of illnesses. The broad disease profile that these individuals experience increases their risk of mortality, reducing their quality of life and placing a serious strain on our healthcare system.
Because they lack basic resources and accessible healthcare, unhoused individuals often only seek treatment in an emergency department (ED) once their conditions give rise to life-threatening complications.
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires all EDs that participate in Medicare to treat and stabilize anyone who arrives for treatment of an emergency medical condition (EMC). As a result, EDs operate as a backward form of universal healthcare—only when patients have an EMC are they entitled to care regardless of ability to pay. This uniquely American system is inefficient and counterproductive, placing a significant financial burden on hospitals that serve unhoused populations.
Homeless patients experience more frequent admissions and utilize more resources than their housed counterparts (often due to concurrent comorbidities). A landmark 1998 study conducted in New York City found that homeless individuals had 36% longer hospital stays, corresponding to an additional cost of $2,414 per day ($5,621.39 in 2024 dollars). This burden is exacerbated by the disjointed nature of follow-up care for the homeless—for those without stable housing and reliable transportation, regular visits to a primary care provider can be impractical. The subsequent lack of treatment adherence creates a vicious cycle of admission and release—seen in substantially higher readmission rates among homeless populations.
Hospitals need more sustainable, efficient, and humane ways of providing care for unhoused populations. Doing so can provide a great service to a community and save valuable healthcare dollars. Several established solutions exist, including shifting the point of care, screening for social determinants of health, modifying discharge plans, and utilizing accessible housing.
Health systems can make treatment more accessible by bringing care to the patient. Street medicine, mobile care, and outreach services benefit homeless populations by removing geographic barriers to care. Changing the setting of care is a foundational first step in meeting the needs of the unhoused.
Screening for housing status and homelessness risk is another way to decrease readmission rates. By asking patients about their housing status when they receive treatment, providers can identify individuals who would benefit from intervention. Collecting and sharing this information with appropriate personnel can keep individuals off the streets and out of the hospital bed.
After discharge, these patients should receive plans designed to support them in protecting their health. Providers should seek to connect patients with housing and service options available to them. Hospitals with sufficient liquidity may also consider investing in the creation of affordable housing in their community—an undertaking that can yield significant returns in the long-term.
The financial upside that comes from helping the homeless population is well-documented. This 2009 study, which employed coordinated transitional housing, subsequent stable housing placement, and continued case management realized a decrease of 3.4 hospital days and 1.3 ED visits per person per year when compared to homeless individuals who received standard discharge planning.
At an average cost of $1,126 per ED visit and $3,120 per inpatient day, a supportive program like this one might be able to reduce costs by more than $120,000 (~$15,000 from reduced ED visits + ~$106,000 from reduced inpatient days) each year for every 10 homeless individuals who receive the intervention. Urban areas and major cities are places where such interventions can make a meaningful change— fourteen cities across the US were home to more than 5,000 homeless people in 2023.
Even something as simple as bringing the right pieces together can have a major impact. This study saw a 71% decrease in ED visits by homeless individuals following treatment at a federally qualified health center by a coordinated care team of case managers, community health workers, and onsite nurses. Using the same cost data, such a program would eliminate ~$60,000 worth of ED visits each year for every 100 homeless individuals who receive the intervention (not accounting for further savings generated from decreased inpatient days following ED visits).
Although simplified, both of these examples reflect existing opportunities for combined financial and humanitarian gain that providers can take advantage of.
Homelessness is not just an individual challenge, but a community one—allowing the needs of the homeless demographic to go unmet creates immense suffering and strains valuable healthcare resources. Offering supportive care while improving margins is a win-win situation for health systems and their patients alike. Healthcare leaders are in a unique position to explore and develop interventions that not only have impactful personal benefit, but also create sustainable improvements for their business models and communities.
One of the most comprehensive and successful approaches to addressing homelessness has been The Boston Health Care for the Homeless Program (BHCHP). The BHCHP has been a pioneer organization in addressing homelessness by demonstrating the importance of widespread integration. It coordinates medical, behavioral, and dental care as well as pharmacy services across hospitals, shelters, and soup kitchens. It enrolls homeless patients in an inter-hospital record system to seamlessly track their healthcare journey. It monitors the health status of homeless populations to diagnose growing community health problems and work with the appropriate organizations in addressing them. Finally, it is self-supporting from a structural standpoint—by designing and advocating for necessary policy changes, enforcing public health guidelines, and repeatedly evaluating internal practices, the BHCHP continually changes to match ever-shifting public health dynamics. In all, the BHCHP has created a remarkable template of success that other healthcare organizations can follow, while providing life-changing services to more than 11,000 homeless people in the Boston area.
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