Health Care for People Experiencing Homelessness—What Outcomes Matter?

The cohort study by Stewart et al1 describes the Safe, Healthy, Empowered (SHE) Clinic, which is colocated with a Seattle, Washington, drop-in community center and serves women experiencing homelessness 4 hours per week on a walk-in basis. Stewart et al1 compared nonemergent (as judged by 2 investigators) emergency department (ED) visits for women who accessed the clinic vs those who had not. While comparison between these groups is limited by selection bias and potential unmeasured confounders, Stewart et al1 report that the 41 women who accessed the clinic 1 or more times had a reduction from 37 nonemergent ED visits in the 6 months before they used the clinic to 22 visits in the next 6 months. A similar reduction was not observed for 35 women who had not used the clinic. More than 567 000 people were homeless on a single night in 2019 in the US, a number that was both an underestimate at the time and widely expected to increase in the wake of the COVID-19 pandemic. Since the onset of modern-day homelessness, health care practitioners have struggled to provide quality care to people who lack one of the most basic necessities for health, housing. The first demonstration programs of specialty clinics for people experiencing homelessness appeared in the mid-1980s, funded by the Robert Wood Johnson Foundation and the Pew Charitable Trust.2 The wrap-around services model was subsequently formalized as the Health Care for the Homeless (HCH) Program in the McKinney-Vento Homeless Assistance Act of 1987. Since that time, specialized health care services for people experiencing homelessness have proliferated. In 2019, 300 health centers received federal funding as HCH sites. Countless other clinics not formally funded under the HCH program—staffed by an assortment of paid employees or volunteers and offering a range of operating hours and services—help to fill various cracks in the health care landscape for people experiencing homelessness. Ultimately, we hope to someday no longer need a specialized system of health care for people experiencing homelessness because the US has committed to making homelessness something that is rare and, when it occurs, brief. Absent that, the value of health clinics serving people experiencing homelessness should be measured by much more than their ability to reduce ED visits. As described by Stewart et al,1 the SHE Clinic emulates many best practices not only for patients experiencing homelessness but for all patients, including meeting people where they are (in this case, both figuratively and literally) and providing on-demand, walk-in availability. Given these strengths, and with the knowledge that multiple studies with more robust designs have found ED visit reduction outcomes in similar populations elusive, we are interested in learning more about other outcomes, such as improvements in housing status, increases in physical and mental well-being, continuity of care, medication management, number of women using preexposure prophylaxis for HIV, and reductions in risk for overdose. These outcomes would not necessarily be reflected in reduced ED use, which is a poor proxy for health, given its multifactorial drivers. Prior to the COVID-19 pandemic, ED visits had continued to outpace what would be expected based on population growth. While we are not sure why, of all the positive outcomes that could result from receiving care in a clinic like the SHE Clinic, Stewart et al1 reported only on ED use, they are certainly not alone in this focus. We suspect the focus on reducing ED use relates to real or perceived pressure from health systems, insurers, and policy makers. Simultaneously, this focus is intertwined with a narrative asserting that increased insurance coverage and access to primary care leads to improved health and, ultimately, reductions in ED use. This simple and intuitive story is the one that + Related article