"I Didn't Have Any Place to Go after the ER": Perspectives of People Experiencing Homelessness and Chronic Health Conditions

Background and Purpose: Homelessness and burdensome chronic health conditions are interrelated social problems. People who lack stable housing experience both a high prevalence of chronic conditions and numerous barriers to accessing care, resulting in health inequities, poor outcomes, and myriad challenges. Within this context, little research has focused on how homeless people with chronic conditions manage their treatment when directly interacting with healthcare and social service systems, and how housing status shapes these interactions. As part of a larger study focused on improving care management and transitions for high-need, high-cost patients with complex chronic conditions, the purpose of the present research study was to explore how people experiencing homelessness view the interaction of their housing status, healthcare encounters, and overall health.

Methods: Semi-structured interviews were conducted with adults who were experiencing homelessness and one or more chronic health issues, such as diabetes, asthma, and mental health problems. The sample (N=21) included 38% women and 43% participants of color. Participants were recruited through a partnership with a large homelessness services organization in Buffalo, NY. Interviews ranged from 15 to 60 minutes. The authors drew on the grounded theory practice of theoretical sampling, simultaneously coding the interviews while collecting data, and honing the interview questions based on themes and gaps that emerged in the data. Three coauthors engaged in primary coding, with each interview coded by two coders using consensus coding procedures. The first author reviewed all transcripts and synthesized themes from the coding process. Strategies for enhancing methodological rigor and trustworthiness of the findings included observer triangulation, team debriefing, and member checking.

Results: Three major themes emerged regarding participants’ perspectives on the intersection of their housing and health. The first, deprioritizing health, reflected participants’ prioritization of survival needs over health maintenance and care, even while experiencing crises related to their chronic conditions. The second theme was the centrality of relationships to healthcare utilization and healing, exemplified by quotations such as, “they [my care team] don't make me feel like it's just a paycheck.” The third theme reflected the confusion that participants encountered navigating the housing/social services and healthcare systems simultaneously. While navigating these systems, most participants prioritized goals related to housing and connected these to potential health impacts, such as getting an apartment with a kitchen to prepare and store healthy food.

Conclusions: Although stable hosing is widely recognized as a social determinant of health, the findings of this study help to address a gap in the research regarding the specific mechanisms through which homelessness and housing instability shape health. The study’s themes indicate the importance of relationality and rapport-building in engaging and retaining homeless patients in health services, and involving them in care planning, so that treatment plans reflect patient goals related to both health and housing. Future research should build from these findings to develop and test interventions for improving care transitions and system navigation experiences for people lacking stable housing.