Addressing Family Homelessness in Pediatrics – Progress and Possibility

Homelessness during pregnancy or childhood should be unthinkable in a society that treats children and families with dignity. In this issue of Pediatrics, Dr. Sandel and investigators from five cities provide new evidence on just how damaging homelessness in pregnancy and early childhood are to child health. Their study, “Timing and Duration of Pre- and Post-natal Homelessness and the Health of Young Children”, included over twenty thousand child-caregiver dyads and found that children who had been homeless were more likely to have prior hospitalizations, developmental delay, and worse health overall. The effects were largest in families who were homeless both before and after a child’s birth, and in families who were homeless for more than six months while their child was an infant or toddler. This study fills a key gap in our understanding, demonstrating the sizable short-term impact of homelessness on child health. It is the latest in a large and growing chorus of evidence on the severe health hazards of homelessness over the lifecourse.¹ It is also a call to action for our profession.

Many pediatric practices have made strides to address family homelessness in the five years since the AAP recommended routinely asking families about whether they have a safe place to call home.² Homelessness questions are part of most clinical screening tools for poverty-related social needs,³ which are becoming accepted as standard of care. Furthermore, once housing-insecure families are identified, practices are increasingly connecting families with programs and services to help them obtain safe and stable housing. A growing number of health systems have even invested in developing affordable housing units,^4,5 supported by financing options for housing-related services from public⁶ and private payers.⁷ Momentum seems to be building for further efforts to adapt the structure and financing of health care to address the needs of homeless populations, spurred in part by cost savings potentially achievable through housing homeless adult patients who incur large medical expenses.^8,9,10 But with the number of homeless Americans rising¹¹ these efforts are not enough to stem the tide. We can and must do more.

First and foremost, we can recognize that the upstream causes of homelessness are alarmingly common and potentially preventable. While far too many families end up in shelters or on the street due to rising costs of living outpacing stagnant wages,¹² this is just the tip of an iceberg of housing-insecure families scraping by in unsafe, overcrowded conditions and whose ranks have nearly doubled over the last decade.¹³ Clinicians and health systems, therefore, have a tremendous opportunity to develop tools that recognize and address housing insecurity to prevent homelessness before it occurs.

One such prevention tool—just-in-time financial assistance to help families weather economic shocks (like unexpected medical bills or job loss)—has been shown to substantially reduce the incidence of homelessness in high-risk populations while saving roughly two dollars to society for every program dollar spent.¹⁴ This result makes sense, given that homelessness is a symptom of broader financial instability.¹⁵ Agencies and municipalities domestically¹⁶ and internationally¹⁷ are discovering that adopting these homelessness prevention approaches keeps financially tenuous families in their homes while offloading demand and shortening wait lists for crisis response housing agencies and permanent supportive housing units. Pediatricians and health systems are in an ideal position to link families to the right community resources tailored to their individual needs, investing in and utilizing crisis response resources when necessary but also preventing eviction through pre-emptive legal or financial services to keep families from becoming homeless in the first place.¹⁸ The main question health systems face is how best to design and implement, in full partnership with agencies and their communities, these kinds of proven homelessness prevention strategies for at-risk families.

Pediatrics has made significant strides toward addressing family homelessness in just a few years. We can make even faster progress by implementing tools to prevent homelessness that transcend current limitations in care coordination, reimbursement, and clinical convention while reshaping pediatric practice to protect child health. Are we ready to advocate as a profession for these innovations and to collaborate with leaders in other sectors to make not just health care but health itself more affordable for our families? Given the evidence on the harms of homelessness for children, doing anything less would be unthinkable.