Doing my nephrology training in San Francisco, CA has made it clear to me that homelessness is an essential health policy issue. 553,742 people experience homelessness in the United States as of January 2017. While San Francisco has less people experiencing homelessness than cities such as New York, NY and Los Angeles, CA (6858 in San Francisco, 76501 in New York, and 55188 in Los Angeles), the lack of a right to shelter policy means that disproportionately more are without shelter.
What are the unique issues facing homelessness in kidney disease?
All individuals who are experiencing homeless face unique challenges, and at our public hospital, we see many patients with CKD and ESKD who are experiencing homelessness. However, data on the effect of homelessness on kidney disease risk factors and outcomes is limited. The ESKD population experiencing homelessness was the subject of an American Nephrology Nurses Association Special Interest Group, highlighting the lack of prevalence statistics and targeted strategies for this population.
A 2014 article from the Journal of Health Care for the Poor and Underserved from Maziarz et al. examined this question. They found that patients with CKD who are experiencing homelessness are at an increased risk of progression to ESKD. When compared to a cohort of domiciled (housed) people with CKD Stages 3-5, people with CKD Stages 3-5 who were homeless had higher incidence rates of ESKD (10.9 for homeless vs. 7.4 for domiciled per 1000 person-years). Homelessness was independently associated with progression to ESKD or death (HR 1.28).
In addition, case series detail the significant challenges that patients with kidney disease experiencing homelessness face. In a case series of eleven patients with ESKD in Canada, nine of eleven were male, and most lived in shelters and had high rates of drug and alcohol addiction. Ten of the patients had unplanned dialysis starts with a catheter. Podymow et al. tell the story of one patient with psychiatric illness, missed dialysis, and violent behavior. He eventually received the psychiatric care he needed and went on to receive a cadaveric kidney transplant. Five years later, he was doing well with preserved kidney function. The authors offer patient-centered strategies to improve adherence, such as:
- Use of once-daily medications
- Prevention of withdrawal
- Involvement of a multidisciplinary care team
Another case series of six patients experiencing homelessness in rural Virginia again detailed the high rates of drug use, alcohol abuse, and mental illness. They were young (mean age ~46), male (6/6), and predominantly black (5/6). Specific considerations related to “hygiene, maintenance of medication regimens, dietary and fluid restrictions, emotional support, transportation, and compliance” were discussed. High sodium and potassium foods were commonly served in shelters and food programs. The authors point out that patients on dialysis who are experiencing homelessness, unlike other people who are homeless, all had health insurance through Medicare, despite lacking basic food and shelter.
What is the way forward?
Many are calling for health systems to increasingly be the purveyor of social resources, which in emergency medicine is termed Social Emergency Medicine. People who are experiencing homelessness have high rates of healthcare utilization, and particularly emergency department visits, making health systems uniquely positioned to deliver social services. Kaiser Permanente, an integrated health system in California, is putting $200 million towards combating the housing crisis. Jeff Bezos, CEO of Amazon and the world’s richest person, is donating $2 billion towards community efforts against homelessness.
What can we do as nephrologists to address homelessness in patients with kidney disease?
- Continue to provide patient-centered care that addresses specific barriers and resource limitations.
- Conduct research in kidney disease and the homeless that will serve as the base for evidence-driven policy implementation. For example, Margot Kushel, Director of the Center for Vulnerable Populations at University of California, San Francisco, researches the causes and effects of homelessness, which led to increased use of medical respite.
- Advocate for affordable housing and resources for the homeless through professional societies and by voting in your local elections. One of the most important questions we can ask our patients is “Where do you live?”
Posted by Sri Lekha Tummalapalli
University of California, San Francisco
NSMC Intern 2018