Making Older Homelessness a Never Event

by Margot Kushel, MD

On April 2, Bevan Dufty, (@BevanDufty) the director of the HOPE program (Housing Opportunity, Partnerships and Engagement) for San Francisco (aka the official responsible for addressing homeless services and outcomes), posted the following message to his 4500 followers on twitter: “86-year old staying @ECS_SF Next Door Polk/Geary shelter needs help walking/feeding small dog. Without dog, client likely returns to street.”

The tweet got me thinking.  I recognize that the only thing worse than having an 86-year old person staying in an emergency shelter is an 86-year old sleeping on our streets.  The tweet was met with a few retweets, likely from others hoping to find a kind volunteer to walk the dog. But I couldn’t find any twitter chatter about the fact that the homeless person in question was 86 years old.  I wondered: have we really become so inured to homelessness that an 86-year old person staying in our homeless shelters provokes no outrage?

The truth is this is not the only 86-year old living on our streets.  This is our new not-so-normal normal. The other day, I got an email from a colleague asking me about what resources were available for an older adult who was about to lose her housing because of behavioral issues caused by aging-related cognitive impairment.   I wish I could tell you that I was able to flood the colleague with resources to prevent her patient’s descent into homelessness, or even a shelter filled with resources designed for an older person with severe cognitive impairment, but I didn’t. 

The terrible truth is that the homeless population is aging at a rate much faster than the general population and we are not ready.  The median age of homeless adults in the United States is over 50, and likely to keep climbing.  We know that people who experience homelessness have an earlier onset of aging-related conditions than does the general population, so that even people in their 50s are likely to have functional or cognitive impairments at a rate seen in the general population in individuals who are in their 70s and 80s.  And yet, as pressure on housing costs continue to mount, as evictions become more common,  and as cognitive and functional impairments limit individuals’ ability to manage the complex steps needed to hold on to one’s housing (or at least forestall the loss of housing) in an unforgiving housing market, this problem is likely to worsen.  And, we are utterly unprepared.

Thirty-something years into the era of modern homelessness, we have learned a lot.  We now have an effective, if expensive, response to chronic homelessness:  permanent supportive housing. Permanent supportive housing (PSH) includes subsidized housing with on-site or closely linked supportive services for people experiencing chronic homelessness.  Chronic homelessness is defined as being homeless for a year or more (or four or more episodes in three years) while having a disabling condition.  PSH has been shown effective at housing individuals who previously had been thought of as unhousable.  While PSH may or may not “save money,” there is no controversy about its ability to serve its most important goal:  housing people with disabling conditions who have experienced long-term homelessness.    While the supply of PSH falls short of the goal, the Federal Government has recognized its success as a strategy and has supported it as the primary route to end chronic homelessness. 

The success of PSH has led to decreases in the proportion of homeless individuals who meet the definition of chronically homeless, but there these decreases have been nearly offset by increases in other forms of homelessness (as evidenced here, here, and here).    This is likely because the gains earned by PSH have been offset by changes in the housing market and economy, leading to increased entry into homelessness.  And, many of those now entering homelessness are older adults whose fixed incomes, higher rates of unemployment, and functional impairments have left them increasingly susceptible to homelessness. Thus, we are faced with the specter of older, frail individuals living on our streets and our shelters.  The system of services for homeless individuals is not suited to older individuals.  While there are a few model programs for older adults who experience homelessness, there is no doubt that the best way to care for an older adult is to prevent their becoming homeless in the first place.

Because I am a physician whose passion is ending homelessness, and because I know how devastating homelessness is to health—particularly on older adults, I started to think about “never events.”  “Never events”  is a term introduced in 2001 by Ken Kizer MD (the former CEO of the National Quality Forum) in reference to particularly shocking medical errors that should never occur.   These are events that are thought to be serious and largely preventable, clearly identifiable, and of concern to the public.  There are currently 29 “serious adverse events” considered to be never events. Many payers (including CMS and many states and private insurers) have adopted policies to not pay for excess costs associated with these events.  In addition, the events are publicly reportable.  By holding healthcare providers accountable—via financial penalties and public reporting—never events have led to intensive efforts by health care providers to prevent these errors.  Financial penalties created financial incentives to spend resources directed at their elimination.  In addition, because payers and others require healthcare providers to conduct root cause analysis of each of these events, we have been able to understand the multiple systemic failures that led to the errors and to reengineer our systems to prevent their recurrence.

In creating the list of never events, no one said that other errors are not important, but instead created a framework to galvanize the response to prevent particularly egregious errors from happening.  In so doing, the creators of never events raised public consciousness about the negative effects of medical errors overall and helped create a culture where patient safety was prioritized. Furthermore, they created a framework for prevention and action. Considering how devastating the experience of homelessness is to health—particularly among frail older adults, I wonder:  what if we decided to make homelessness among frail older adults a  never event?  What if we chose an age—or a level of disability—for which we agreed that the experience of homelessness was so unconscionable—that we could agree to label it a never event.  What if we agreed to examine the root causes that led to homelessness among someone who was 86, or 75, or 65 or 60 and said:  never again?  What if in doing so, we chose to align our resources and policies to prevent homelessness among frail older adults from ever happening?  In doing so, we wouldn’t be saying that any form of homelessness was acceptable, only that there are some situations so intolerable that it offends our sensibilities enough that we pledge to make sure it never happens again.  I am not saying it would be easy, but maybe it would create just enough momentum that we would never again sit by helplessly when we heard about a frail older adult trying to live on the streets or in our shelters.