California, Homelessness, Mortality Prevention, and the Other Homeless Count
An unknown number of adults and children including infants
die while homeless throughout California each year
Future state legislation and homelessness strategies
should include more actions that focus on mortality prevention
that help fulfill recommendations described in this report
Several organizations in many California counties and cities each year produce “the other homeless count,” a count of local persons who died while homeless. Each person counted is recognized by name during a public commemoration on December 21st Homeless Persons’ Memorial Day, which was established to include raising awareness of the need for mortality prevention.
That approximately 5,000 adults and children died while homeless in 2021 throughout California’s 58 counties may be a conservative estimate as recently noted in a published story in the New York Times. The U.S. Interagency Council on Homelessness stated that approximately 16,000 people died nationally while experiencing homelessness in 2021 and “sadly, this is likely a vast undercount.”
Mortality data from just four California county Medical Examiner-Coroner offices, reveals that approximately 2,200 adults and children died while homeless in 2021. Acquired data from the Public Services Division of the Los Angeles County Department of Medical Examiner-Coroner (ME-Coroner) by Urban Initiatives revealed that during 2021 more than 1,400 persons who were examined died homeless, which is an average of nearly four persons per day.
Nearly 400 persons died while homeless in Orange County during 2021 or approximately one person per day. Nearly 200 people died while homeless in Sacramento County during 2021 or about four persons per week. Acquired data by Urban Initiatives from the Public Services Division of the San Bernardino County Department of ME-Coroner revealed that close to 200 people died while homeless in the County during 2021 or approximately three persons per week.
Manner of Death
ME-Coroner data categorizes the mode or manner of death as accidents, natural causes, homicide, and suicide. Accidents included blunt force trauma, drug effects, toxicity from cocaine, heroin, methamphetamine, and fentanyl, multiple drug intoxication, and smoke inhalation.
Natural causes included arteriosclerotic cardiovascular disease, complications due to diabetes and obesity, heart disease, hepatic cirrhosis, hypertensive cardiovascular disease, peritonitis, pulmonary embolism, sepsis and septic shock, and sudden cardiac arrest.
Homicide included gunshot wounds, stab wounds, blunt force injuries, or strangulation. Suicide included blunt force trauma, gunshot wounds, hanging, and acute toxicity.
Infant deaths are also recorded and described in ME-Coroner data. An Orange County report noted in the Orange County Register that
Three infants were among the homeless people who died in the county last year, matching the number of infant homeless deaths recorded during the previous 11 years. All three were younger than 1 year old, and two were found to have died from their mother’s drug use. One boy was stillborn after he overdosed on methamphetamine while still in the womb. The other, born prematurely, died at one month after his brain hemorrhaged.
LA County ME-Coroner mortality data acquired by Urban Initiatives also included infants whose cause of death was peripartum neonatal demise, intrauterine fetal demise, effects of fentanyl, heroin, and methamphetamine, prematurity with traumatic injuries, probable malnutrition/starvation and extreme prematurity.
Initiating, increasingly integrating, and intentionally directing Street Outreach and Street Medicine Team efforts immersed in trauma-informed care will enhance mortality prevention and result in more lives saved by these teams.
Street Outreach and Engagement
Street outreach and engagement teams identify and engage adults and children living in abandoned buildings, encampments, make-shift shelters, tents, and vehicles and also living exposed and uncovered on sidewalks, in parks, and in parking lots, and other places not meant for human habitation. They are particularly skilled at identifying and engaging people who are chronically homeless and languishing on the streets and who are increasingly vulnerable to illness, injury, and death.
All team members should be skilled at integrating a trauma-informed approach into their street outreach and engagement activities to help the people they encounter obtain temporary and/or permanent housing. Additionally, all team members should fully understand the premise that past and present trauma affects the ability of people languishing on the streets to overcome their homelessness experience.
Street medicine efforts involve providing health care to the most ill and vulnerable people living homeless on the streets. The goal is to remove barriers that make them sicker and more likely to die, such as scheduling appointments, finding transportation to a clinic, picking up prescriptions, and paying for their treatment.
Effective street medicine efforts prevent minor health conditions such as cuts and infections from becoming life-threatening and significant health conditions such as heart and lung problems resulting in death.
Furthering the integration of street outreach with street medicine is imperative because lives can be saved. Street outreach workers can help ensure that street medicine care is provided to persons languishing alongside the streets and who are also most vulnerable to illness, injury, and death.
As is the case with street outreach teams, all street medicine team members should also be skilled at integrating a trauma-informed approach into their activities. In addition, all team members should fully understand the premise that past and present trauma affects the ability of people languishing on the streets to overcome their homelessness experience.
Street outreach and street medicine teams need to fully understand that the lasting effects of trauma and the fear of being re-traumatized may cause too many people to live on the streets in a constant state of survival. This constant state of survival is likely to prevent many of them from taking the steps necessary to get off the streets, as counter-intuitive as it may seem.
Street outreach and street medicine teams should ensure that people living in a constant state of survival on the streets experience them as teams committed to safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice, and choice. Teams should also ensure persons they serve on the streets know that they are committed to cultural, historical, and gender issues while helping each person take the necessary steps to obtain and maintain permanent housing.
The other homeless count adds to the urgency to carry out the recommendations included in Mortality among People Experiencing Homelessness in Los Angeles County: One Year Before and After the Start of the COVID-19 Pandemic.
The report detailed 20 recommendations that focused on
- Enhancing and expanding field-based substance use disorder and other health care treatment;
- Expanding and improving substance use disorder services;
- Expanding peer-based outreach through street-based syringe exchange and overdose prevention education;
- Expanding and enhancing county-contracted substance use disorder provider utilization of the Homeless Management Information System (HMIS) to improve coordination of care and housing-focused case management;
- Increasing investments in recovery bridge housing;
- Implementing infectious disease protocols in encampments;
- Continuing annual surveillance of mortality among persons experiencing homelessness in LA County including a geographic analysis of traffic injury and homicide deaths, and review a subset of deaths in more depth; and
- Conducting analysis of administrative data records of deceased persons experiencing homelessness in coordination with County departments and academic partners, to reduce homeless mortality.
To read the report click here.
The other homeless count also adds to the urgency to carry out our recommendations, which include
- Integrating Medical Examiner-Coroner’s Records of Persons Who Died While Homeless into HDIS
Since its recent inception, the Homeless Data Integration System (HDIS) has already provided an unprecedented level of data to help improve planning, policy, and services regarding homelessness statewide. Questions are now being answered that have not been answered before, which can also include questions about dying on the streets while homeless.
In California, each county Coroner Office’s responsibilities include tracking and reporting mortality information that involves determining the manner of death, injury description, causes of death, and residency. In addition, basic demographic data, such as gender, race, and age, are also recorded. This information is often used collectively to provide insights into health threats and disparities, improve outbreak and disaster response efforts, and expose circumstances surrounding sudden, unexpected, and unnatural deaths. This information is also used to compare death trends between cities and counties.
There are 60 Coroners & Medical Examiners in California, according to countyoffice.org.
- Creating a State Repository for De-identified Records of Persons who Died Homeless and Integrate them into HDIS
The State of California should create a repository of all records for persons who died while homeless, according to Coroners’ offices data. Integrating the repository data into HDIS would provide an unprecedented opportunity to create new, or improve existing, planning and policies and increase temporary and permanent housing and services for persons languishing on the streets prone to injury and death.
Integrating the repository data could help, among other proactive actions,
- Determine what steps can be taken to prevent the loss of life. Information from Coroner records can raise awareness of problems such as the high incidence of blunt force trauma by vehicles and trains;
- Signal a larger public health emergency such as infectious diseases including Hepatitis C. Some California counties have declared a local health emergency in the past as a result of an outbreak of Hepatitis C that resulted in some deaths;
- Discover if a week of the month, month of the year, or a time of year has the highest death rates in order to heighten street outreach and other outdoor interventions during a critical period of time; and
- Decide if there are types of locations such as open areas like parks and fields, freeway underpasses, and industrial zones in cities and zip codes where higher concentrations of persons die homeless in order to heighten street outreach and other outdoor interventions within such locations.
However, at this time, tracking and reporting mortality is a complex and decentralized process with various systems used by California Coroner’s offices. Some uniformity should be required prior to the creation of the repository that includes:
- using a common definition of homelessness to determine homelessness;
- phasing out any paper-based systems and replaced with reputable software; and
- upgrading any outdated electronic systems.
Our recommendations also include
- Conducting an in-depth case review of a sub-set of all persons experiencing homelessness (PEH) deaths to develop a more comprehensive understanding of the circumstances surrounding these deaths and inform mortality prevention efforts;
- Creating a Homelessness Mortality Prevention Task Force that includes a diverse range of experts and researchers charged with sharing best practices on how localities can carry out mortality prevention, discussing how to best organize mortality data reports, and planning advocacy work based on homelessness mortality data; and
- Encouraging the observation of Homeless Persons Memorial Day (December 21).