Hawaii Hospitals Are Struggling To Meet The Needs Of The Chronically Homeless

Every day, nearly two dozen homeless people make their way to an emergency room in The Queen’s Health System seeking care. 

Some are in the throes of a serious medical emergency. Others need treatment for a minor ailment. Some are simply desperate for a hot meal. 

The staggering number — 8,228 visits by 2,850 homeless people in the last full year before the pandemic — makes Queen’s one of the largest homeless service providers in the state.

Yet the hospital is often not the best place for them to get help — a fact that was highlighted last week in news reports about a homeless man who lay on the sidewalk outside of the Queen’s emergency room at Punchbowl for nearly a week before getting transported somewhere else for the help he needed.

The barriers to providing adequate care to homeless people at emergency rooms are myriad. Emergency room physicians have few mechanisms to provide follow-up care to people living on the street. ER visits are much more costly to taxpayers than treatment at a clinic. There’s not even a way for doctors to make sure the homeless people they treat in the ER will be able to get prescriptions filled after they are discharged. 

Addressing those challenges could have significant impact.

More than two-thirds of homeless individuals on Oahu who sought acute care in recent years did so through the Queen’s system, said Dr. Daniel Cheng, an emergency room physician and head of the Queen’s Care Coalition for the homeless.

That makes the hospital a unique place to focus on triaging the many needs of the chronically homeless — a goal that Cheng said is important not only for addressing the low life expectancy of people living on the streets, but also the high cost to society of leaving people trapped in a revolving door at the emergency room. 

“We know that 70% of the homeless population accessing the acute care system are coming to Queen’s at some point within a year,” Cheng said. “That’s a leverage point I feel is being untapped by the state.”

Working In Silos

Honolulu has made some big efforts to improve medical care for homeless individuals in recent years. The city is expanding its Crisis, Outreach, Response and Engagement program, which sends teams of EMTs and community health workers to respond to non-emergency homeless calls. And it opened a medical respite center in 2021, with 18 beds for homeless people who need space to recover from an illness but don’t require hospitalization. 

But Hawaii’s medical system should be doing more to prioritize the system’s highest users and most complex cases, Cheng said. 

“These are the ones that we know are going to have a lifespan under 60ish years,” Cheng said. “They’re also the highest cost for the state as well. So there’s multiple — from my perspective — reasons why we should be rolling out the red carpet for them.”

Cheng helped Queen’s launch the Queen’s Care Coalition in 2018 to try to bring best practices from across the country to Hawaii to help address what he describes as a “broken system” with homeless care providers often working in silos.

As an example, Cheng points out that as recently as 2015, Oahu hospitals didn’t have access to the county’s Homeless Information Management System, which allows homeless service providers to coordinate care for people experiencing homelessness. When he was able to gain access, he found that only two of the 100 homeless individuals identified as top utilizers of hospital services were in the information system.

The Queen’s Care Coalition employs social workers and health care navigators to help homeless people get connected to more long-term care at community health clinics and gain access to housing and other services that might prevent them from ending up back in the emergency room in the future.

The program has had real success in reducing the number of ER visits for patients it works with, but it reaches only a fraction of the individuals accessing emergency services each year — 322 individuals between January 2018 and September 2019.

One challenge is aligning goals across the entire health care system when it comes to high-needs patients, Cheng said.

Better alignment might look something like this, Cheng said: A homeless individual comes into the emergency room with an injury that needs treatment but isn’t deemed a medical emergency.

A homeless service worker — perhaps someone employed by Queen’s or a state employee assigned to the hospital in this idealized scenario — would call one of the island’s community health clinics to arrange for the patient to be seen there immediately. At the same time, the worker would enter the person in the homeless management information system, make sure their food stamps are up to date, double check that the person is on a housing voucher list, then put them in a taxi or other form of non-emergency transportation to the clinic.

“There’s about five to eight checklist things that every homeless person should go through when they come through the doors of the emergency department,” Cheng said. “Right now maybe we’re doing one.”

As it stands, there is no easy mechanism for ER workers to easily have patients transported to community health clinics — even though medical transportation is reimbursable by Medicaid, Cheng said.

Such a scenario would require a larger investment — Queen’s spends about $1.5 million a year on the coalition but does not get homeless funding from the city, Cheng said.

It would also necessitate changes in how other facilities operate. Many community health clinics close by 5 p.m., whereas the bulk of emergency room visits by homeless people tend to be in the late afternoon and evening.

As it is, Kalihi-Palama Health Center — one of the main community health clinics that Queen’s partners with — is struggling with staffing for the hours and services it provides.

“Getting doctors, nurses, medical assistants, social workers, getting the workforce — even folks to our front desk, even getting security, It has been a challenge,” said Darrin Sato, chief operations officer at Kalihi-Palama.

Expanding CORE Services

One way that Honolulu is trying to alleviate the strain on emergency rooms is through the Crisis, Outreach, Response and Engagement program. The CORE program, which is run by Honolulu Emergency Services Department, sends ambulances staffed with EMTs and caseworkers to respond to non-emergency homeless calls.

CORE has interacted with more than 1,000 homeless individuals since its inception in 2021 and provides a slew of services, from helping people get signed up for health insurance, to getting homeless people identification, transporting people with medical needs to a clinic at the John. A Burns School of Medicine, and helping people get into emergency or transitional housing, said Honolulu EMS Director Jim Ireland, who oversees CORE.

CORE operates from roughly 7 a.m. to 5 p.m. seven days a week, and focuses its efforts primarily in urban Honolulu. It currently employs around 30 people, but is looking to hire another 20 workers this year and have a larger presence in other parts of the island, Ireland said.

Like the Queen’s Care Coalition, CORE is looking to other cities grappling with high homeless populations to find new ways of addressing serious needs here.

“We’re trying to be innovative,” Ireland said. “We’re trying to learn what other cities are doing that is working, and we are making progress.”

CORE has been able to reduce the frequency of emergency room visits among the individuals it services, Ireland said. Finding enough staff to expand the program has been a challenge, though.

To have more of an impact, the city also needs more shelter beds and more medical respite beds where CORE workers can take people. And the state needs more spaces for people who have physical or mental illnesses that are serious, but not severe enough to require hospitalization.

“There are these folks in the middle,” Ireland said. “They do have serious mental illness or drug abuse problems or have serious medical problems, but they’re not severe enough to be in the hospital. We need some place for those folks to go.”

One thing thing that Ireland and Cheng both agree on is the need for better coordination in Hawaii.

Seattle, which has one of the highest per-capita homeless populations in the country, recently opened up an emergency operations center to respond to homelessness. Honolulu has an emergency operations center that it opens up when there’s a tsunami or hurricane, Ireland said, to coordinate its emergency response.

The state might not need a manned in-person emergency operations center, but some sort of virtual system to bring stakeholders together each morning to address community concerns and needs might be helpful, Ireland said.

Part of that coordinating needs to be a shift in homeless funding that prioritizes the highest services utilizers in the state, people who may come to the emergency rooms more than 100 times in a single year.

“As an ER physician, there are significant implications of not addressing homelessness in Hawaii. And I’m seeing it at the very ground level,” Cheng said.

That includes delays in EMS response times and emergency room care when medical workers are responding instead to non-emergency homeless calls, and a drain on community resources when police are dealing with mental health crises on the streets, Cheng said.

“Besides just the dollars, there’s a real physical cost that we’re all kind of not really seeing.”

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.