In 2018, the U.S. Department of Housing and Urban Development estimated that more than half a million people experience homelessness on any given night. Many find shelter in our emergency departments.

City governments across the country—such in as Los Angeles, New York City, and Boston—have mobilized significant resources to address homelessness by creating housing units meant for the homeless and implementing greater supportive services. The problem with this approach is that these city and statewide efforts don’t coordinate with the most crucial partner in the ecosystem of services that care for the homeless: hospitals.

The result is a cycle of missed opportunities that plays out nightly in emergency departments across the country.

Could the implementation of housing navigators—specially trained experts in housing placement who have been traditionally used outside of the hospital setting—as ED staff be the answer?

In the absence of more robust, permanent supportive housing units, I propose that there is no other intervention that could have a more significant impact on ED care for the homeless than implementation of ED-based housing navigators. Consider the recent case of a patient in our emergency department.

Terry’s Story

It was 2 a.m. and 2°F outside in Boston. We were about to discharge Terry (whose name was changed for this story) from our department for the second time in 24 hours. Terry was homeless, and this was our routine all winter last year, especially when it was too cold for him to sleep under a highway overpass or in shop doorways downtown. Many times, he was drunk, and so we monitored him until he was sober enough to walk out. Other times, he concocted medical issues that needed to be urgently evaluated, excuses that he (and we) knew would keep him in our emergency department safe and warm, at least for a few hours.

That night, my colleague was the provider caring for Terry. I showed her a list I’d been given of high utilizers of emergency services (and yes, the term “frequent flier” is derogatory). This list contained the top 50 homeless utilizers of the city’s emergency services, their housing status, and where they were on the path to being placed in city housing.

It is remarkable that the city even has such a list. But the city’s major problem? Due to the nature of homelessness, it has trouble simply locating these patients. A colleague who worked for the Department of Public Health thought that, as an emergency physician, I might be able to keep an eye out for patients on this list who presented to the emergency department. This particular list is one of nearly a dozen distinct housing lists that create a disconnected and complex patchwork of resources that weaves together the housing system in Boston.

My colleague’s eyes fixed on the screen. There was Terry’s name. Not only did he already have a housing voucher assigned to him, he also had a city-owned apartment waiting for his arrival. He had never checked in.

Later during that shift, we contacted Terry’s case manager, and while he was in the hospital, preparations were made for him to move in. He was later discharged. To his new home.

Terry’s case was exceptional in that the stars aligned. He happened to have available housing and an effective outpatient case manager. But his case is not unique. There are patients who are in the same situation as Terry. Sadly, hospitals that see these patients are often kept in the dark.

Usually, hospitals simply discharge patients like Terry back to the streets with a list of shelters. We don’t fundamentally advance them on the pathway toward housing. I hear you asking, should we? My answer is yes.