How Can We Improve Surgical Care of Patients Who Are Homeless?

Abstract

The Current State of Surgical Care for Patients Who Are Homeless Homelessness is a national crisis. In the US, 580 466 people experienced homelessness on 1 night in 2020, up by 2.2% from 2019. 1 Compared with housed individuals, unhoused people have higher rates of chronic health conditions and mental illness, are hospitalized younger, and face barriers to obtaining adequate primary and preventive health care. To date, much of the scientific literature has focused on the medical and psychiatric care of the homeless population, with little research performed to guide surgical teams in tailoring surgical care and ensuring equitable delivery to the unhoused. Housing status undoubtedly affects surgical management, from preoperative assessment and preparation to intraoperative decision-making to postoperative care and rehabilitation (Figure). As homelessness rates rise, equipping surgeons with the tools to provide equitable, patient-centered care for this vulnerable population will be vital.The intersection of homelessness and surgical conditions has been evaluated in few studies. The largest cohorts come from national registries, like the Veterans Administration (VA), including a study by Titan et al 2 that found disproportionately higher rates of readmissions in patients who are homeless discharged to the community following surgery. The limited literature highlights risk factors for surgical complications or issues with postoperative care in the homeless individuals, like increased risk of infection or higher rates of readmission, usually in small series. Very few studies have identified strategies to address these inequities.

Individuals Experiencing Homelessness: A Systematic Review of Otolaryngology‐Related Health Needs and Community‐Based Interventions

“…In one study, patient navigators were found to increase both screening rates for cancer and adherence to diagnostic follow‐up by approximately 10% and were found to be cost‐effective 62 . Lastly, improved documentation of housing status in electronic medical records and administrative databases has been identified as a strategy to improve the identification of individuals who may benefit from additional support in addition to improving research on the health of persons experiencing homelessness 63 …”

“…62 Lastly, improved documentation of housing status in electronic medical records and administrative databases has been identified as a strategy to improve the identification of individuals who may benefit from additional support in addition to improving research on the health of persons experiencing homelessness. 63 There were several shortcomings and a great deal of heterogeneity between the studies included in this review. The heterogeneity limited the ability to perform a metaanalysis and further synthesize the results.…”

Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness

“…1 Lack of stable housing is an important healthrelated social risk factor. 2,3 People experiencing homelessness (PEH) face substantial barriers to primary care, resulting in higher rates of emergency department (ED) utilization. [4][5][6][7][8] PEH also have increased mortality rates compared with the general population.…”

“…An estimated 580 000 people experienced homelessness in the US on any given night in 2020, with increasing volume during the COVID-19 pandemic . Lack of stable housing is an important health-related social risk factor . People experiencing homelessness (PEH) face substantial barriers to primary care, resulting in higher rates of emergency department (ED) utilization .…”

Prospective Assessment of Social Determinants of Health and Length of Stay Among Emergency General Surgery and Trauma Patients

“…Importantly, social determinants of health (SDOH) such as housing, substance use, and employment affect LOS in ways that are difficult to quantify and vary independently from primary medical diagnosis. 2 The acute care surgery (ACS) population, which includes emergency general surgery (EGS) and trauma patients, is particularly vulnerable to social and health disparities that can affect LOS. [3][4][5][6] These discrepancies and associated difficulties with reimbursement and resource utilization due to LOS beyond predicted for a patient's DRG have led some centers to question its validity as a quality measure in this population.…”