In the last month, I have used the ICD-10 codes Z59.0 (homelessness), Z59.1 (inadequate housing) and Z59.9 (unspecified housing or economic problem) far more than I ever would have imagined. Several patients came into my urban clinic with varied chief complaints, including issues with uncontrolled asthma, chest pain, stress, worsening knee pain and sciatica. However, after listening and asking questions, I quickly realized that all of these initial complaints shared a commonality — distress about housing.
My first patient had recently left transitional veteran housing provided by Volunteers of America to get his own permanent housing elsewhere. However, he soon realized the housing conditions at his former residence were much better than the rodent-, cockroach- and mold-infested single-room occupancy he had been granted by the local housing authority. His new residence also featured a caved-in roof.
During his visit with me, he requested adjustments to his asthma medications. The numerous triggers he encountered at his new address had already led to an emergency department visit earlier in the month. He asked me to write a letter to the housing authority, communicating the severe consequences the poor environment was having on his health. I learned then that inadequate housing is a billable diagnosis if there is lack of heating, restriction of space, technical defects in the home preventing adequate care, or unsatisfactory surroundings.
A week later, another patient followed up with me regarding an orthopedic surgeon’s evaluation for her severe bilateral knee osteoarthritis. Although she agreed that total knee replacements were likely in her near future, she had no way to heal properly after surgery if she continued to live in her fifth-floor walk-up apartment. I wondered how she could even move into a new home in her current condition. The last patient I saw — an elderly male — openly wept about having nowhere to go after completing a month of medical rehabilitation. He was essentially homeless, exchanging food stamps for a space on a not-so-good friend’s couch.
My response to these stories and others was to reassure patients that I have someone who can help them. My clinic is a patient-centered medical home, and we have in-house case management services by professionals who are familiar with community resources and services. The case managers can help make referrals outside the medical establishment to help address some of the social determinants of health that impede patient wellness. I was surprised to find out, however, that the case managers felt overwhelmed by the number of housing requests being referred to them.
In a general staff meeting, we were encouraged to set realistic expectations for patients prior to their visits with the case manager. Many patients were coming to the visit thinking their housing woes would be quickly resolved. However, the reality was bleak because affordable housing in New York City is becoming harder to find and the shelter system is overwhelmed. A case manager said gentrification was the problem. The prognosis was not good for the established members of our community. There is limited housing, higher rent, and uncertainty about families’ continued existence in a neighborhood they can no longer afford.
As a physician, I might be in the best position to advocate for my patients and find the best resources to improve their wellness. That became quite clear a month ago. I had written a letter that resulted in a patient’s getting a new home that accommodates her medical needs. Her enthusiastic hug and sincere appreciation reminded me that my role as a physician extends beyond physical exams and prescription writing. It is about advocating for my patients and the community I serve. If I want to truly help my patients and address social determinants of health, I have a responsibility to learn more and do more about housing. We can no longer relegate this issue to the realm of social work and case management.
Venis Wilder is a family physician.
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