Every single Emergency Department in the United States treats unhoused patients on a daily basis, and their needs vary greatly from ICU level care to the common cold. According to the National Alliance to End Homelessness, in January 2023, there were an estimated 653,104 people experiencing homelessness on a given night (1). The numbers continue to rise and between 2019-2023, there was a greater than 12.1 percent increase in the number of individuals experiencing homelessness for the first time (1). By one estimate, every night in Illinois, approximately 11,947 people per night are unhoused (2). By another estimate, this is even higher, with possibly over 18,800 people per night without housing in Chicago alone (3).
Housing insecurity is correlated with other health issues as well. Without housing, it is much more difficult to manage medical and psychiatric issues, especially for those also dealing with substance use disorder (4). As our population increasingly ages, a new challenge will arise with the need for safe disposition planning for elderly individuals experiencing homelessness.
Proposed Solutions
There are no simple answers to a problem that affects so many millions of people per year, but there are ways to start addressing it and offer help on individual and systems levels.
One system-level approach is called Permanent Supportive Housing (PSH). This generally targets individuals who have experienced prolonged and repeated episodes where they do not have housing and offers them long-term assistance (5). Another solution, known as rapid rehousing, is much broader, designed to fill short-term gaps in housing, and can include short-term rental subsidies to keep people in housing (5).
PSH does face some barriers, and it can be difficult for individuals to meet current requirements to stay in housing programs, such as requiring individuals to stay sober and/or achieve stability on psychiatric medications (4). A 2020 analysis by Peng et al. looked at twenty-six studies comparing Treatment First programs to Housing First programs, the latter getting individuals into housing without requiring sobriety. According to their analysis, homelessness decreased by 88% in Housing First programs, a dramatic improvement, and housing stability increased by 41% (4). This makes an excellent argument for Housing First, and it’s unsurprising that by offering individuals stability through housing, it also decreases barriers they may face to achieving sobriety or stability for psychiatric conditions while unhoused.
As much as this is an ideal solution, what can we do for patients in the meantime given many may not meet requirements for PSH and the length of waiting lists for many assistance programs in general?
What Can We Do in the Cook County Emergency Department:
Screen patients who are ED high utilizers for housing insecurity
Provide thorough medical screening exams knowing that housing insecurity exposes patients to great health risks
Allow patients a change of clothes to decon prior to discharge
Get to know community resources for your patient population that involve both short-term housing options and long-term housing options
What Are We Doing:
The Cook County Emergency Medicine Residency is piloting a program called Resident as Resource. Through engaging and developing close relationships with community resources, our residents provide forms mimicking prescriptions (e.g. social prescribing) that refer to these patients to community resources with which we have an established relationship. This form, in theory, notifies the community resource a) this patient came from our Emergency Department, b) that our residents have screened and determined this patient needs social assistance, and c) that they can help alleviate those social burdens for this patient. This is done under the guiding principle that more than just medication prescriptions can provide good health solutions and give them to patients in the Emergency Department with identified social needs.
Authored by Dr. Amanda Dahl and Dr. Rashid Kysia
References
1. Soucy D, Janes M, Hall A. State of Homelessness: 2024 edition. National Alliance to End Homelessness. August 5, 2024. Accessed July 10, 2025. https://endhomelessness.org/state-of-homelessness/.
2. National Alliance to End Homelessness. SOH: State and CoC Dashboards. National Alliance to End Homelessness. March 18, 2025. Accessed July 10, 2025. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-dashboards?State=Illinois.
3. Chicago.gov. Point in Time (PIT) Count. City of Chicago. 2025. Accessed July 10, 2025. https://www.chicago.gov/city/en/depts/fss/provdrs/emerg/svcs/PITcount.html.
4. Peng Y, Hahn RA, Finnie RK, et al. Permanent supportive housing with housing first to reduce homelessness and promote health among homeless populations with disability: A community guide systematic review. Journal of Public Health Management and Practice. 2020;26(5):404-411. doi:10.1097/phh.0000000000001219
5. National Alliance to End Homelessness. Housing First. National Alliance to End Homelessness. March 20, 2022. Accessed July 10, 2025. https://endhomelessness.org/resources/toolkits-and-training-materials/housing-first/.