Dying While Homeless is a Burgeoning Crisis in California That Necessitates Systemic Changes

Infants and Fetuses are Among the Dead

  • Assembly Bill 271 Authorizes Counties to Establish a Homeless Death Review Committee 
  • National Health Care for the Homeless Council provides and promotes guidance for jurisdictions to create and implement a Homeless Mortality Workgroup

Recently acquired data from the County of Los Angeles Department of Medical Examiner-Coroner (ME-Coroner) revealed that approximately 2,000 persons died while homeless during 2023 (approximately five persons per day) including those noted under the age category as age 12 months or less.

Four infants aged 12 months or less were listed. The cause of death for two of the infants was noted as “sudden unexpected infant death.” Acute respiratory tract infections and virus was noted as the cause of death for one infant and an accident was noted as the cause of death for one infant. Intrauterine Fetal Demise also known as stillbirth was noted as the cause of death for six fetuses.

San Bernardino Department of Medical Examiner-Coroner 2023 homelessness and mortality data obtained by Urban Initiatives revealed that approximately 300 persons died while homeless. The data also noted age 0 under the age category. The cause of death for one fetus was Intrauterine Fetal Demise and Chorioamnionitis. For the other fetus, at 30 weeks gestational age, the cause of death was cardiorespiratory failure and multiple congenital anomalies.

The Sacramento County 2023 coroner data revealed that over 200 persons died while homeless. The data also noted that a 4-day-old infant who was considered to be homeless died at a hospital.

Orange County Sheriff’s Coroner Division data report noted that nearly 500 (496) persons died while homeless. Three deaths were also recorded and described in recent Orange County ME-Coroner data regarding fetuses. 

Assembly Bill 271 Approved by the Governor in September 2023

California Assembly Bill 271 which authorizes counties to establish a Homeless Death Review Committee states

This bill would authorize counties to establish a homeless death review committee for the purposes of gathering information to identify the root causes of death of homeless individuals and to determine strategies to improve coordination of services for the homeless population.

Information gathered by the homeless death review committee and any recommendations made by the committee shall be used by the county to develop education and prevention strategies that will lead to improved coordination of services for the homeless population.

The legislation went into effect in January 2024.

Establishing a Homeless Death Review Committee

The National Health Care for the Homeless Council (NHCHC) provides a Homeless Mortality Data Toolkit: Understanding and Tracking Deaths of People Experiencing Homelessness that promotes guidance for jurisdictions to create and implement a Homeless Mortality Workgroup and can provide guidance for California’s counties to establish a Homeless Death Review Committee.

Guidance involves:

  1. Identifying and including appropriate committee members;
  2. Sources of homeless mortality data;
  3. Methods for measuring deaths among people experiencing homelessness;
  4. Creating a homeless mortality report;
  5. Calculating homeless mortality rates among people experiencing homelessness; and
  6. Long-term needs.

NHCHC notes on page 12 of its Homeless Mortality Data Toolkit that their report provides a high-level overview of the most common mechanisms used for collecting and reporting on homeless mortality. We hope that health and housing advocates can learn from this information to inform their efforts to create and carry out ongoing homeless mortality data reporting efforts on a local, state, and national level.

  1. Identifying and Including Appropriate Committee Members

AB 271 does not provide examples of appropriate committee members for a Homeless Death Review Committee. NHCHC provides guidance in this regard on page 13 in its Homeless Mortality Data Toolkit and suggests that health department and community partners appropriate for a task force/working group can include: 

  • Medical Examiner/Coroner leaders
  • Health department, epidemiology, and public health leaders
  • City/County Homeless Department leaders
  • Health Care for the Homeless (HCH) programs or other health centers
  • Homeless Management Information System (HMIS) Continuum of Care leaders
  • Homeless services providers
  • Hospitals, health plans
  • People experiencing homelessness (PEH)
  • Community providers and advocates.

NHCHC also notes on page 12 of its Homeless Mortality Data Toolkit that It is scarcely possible to initiate a homeless mortality report independently. Successful reports, rather, emerge from a collaborative task force or work group that focuses on accountability, brings in multiple points of view, provides partnerships and data-sharing, reviews results, and carries out recommendations. Such work groups must partner with health department leads.

  1. Sources of Homeless Mortality Data

Sources of homeless mortality data listed and described on pages 13 – 14 of the NHCH Toolkit include:

  • Coroner’s Office/Coroner’s Report
  • Office of Medical Investigator/Medical Examiner Report
  • State Death Records
  • Community-Based Primary Data

Mortality data in most jurisdictions reside with the Coroner’s Office.

  1. Methods for Measuring Deaths Among People Experiencing Homelessness

Methods for measuring deaths are described on pages 17 – 20 of the NHCH Toolkit.

Methods for measuring deaths involve identifying persons experiencing homelessness at the time of death and recording demographic characteristics and information about the mode and manner of death. Homelessness is often noted under type of residence by the Coroner’s Office. Mode of death is often categorized under accident, homicide, natural causes, and suicide.

In a report that Urban Initiatives recently completed concerning homeless mortality in Los Angeles County, the following was noted regarding mode and manner of death.

Accidents often include blunt force trauma including multiple injuries and head injuries, drug effects, toxicity from cocaine, heroin, methamphetamine, and fentanyl, or multiple drug intoxication, and smoke inhalation and homicide which often includes gunshot wounds, stab wounds, blunt force injuries, or strangulation.

Natural causes often include complications due to diabetes and obesity, heart disease, pulmonary embolism, sepsis and septic shock, and sudden cardiac arrest. Suicide often includes blunt force trauma, gunshot wounds, hanging, and acute toxicity.

  1. Creating a Homeless Mortality Report

For creating a homeless mortality report, NHCHC notes on page 20 that each jurisdiction’s homeless mortality report will differ. The NHCHC recommends a close review of the reports referenced in their toolkit (Appendix B) to find a format and method that works best based on the type of data available and the amount of work that can be put into the project.

Their recommended key elements include:

  • Definitions
  • Categorizing causes of death by type and demographics
  • Locations of death
  • Focus on special issues (overdose, substance use, homicide, suicide, accidents)
  • Homeless mortality rates vs general population
  • Recommendations
  1. Calculating Homeless Mortality Rates Among People Experiencing Homelessness

The NHCHC Toolkit notes on pages 20 – 21 that calculating homeless mortality rates often demonstrates that people experiencing homelessness (PEH) have higher mortality rates than the general population and that local data that quantify these mortality rate differences can be a powerful tool for advocating policy and programmatic action to reduce this disparity and support prevention efforts.

NHCHC briefly describes a “Direct Method” for which you will need a “standard” population to which you apply age/gender specific mortality rates for your PEH population and your community population and it is common to use US census population as the standard population.

  1. Long-term Needs

The NHCHC Toolkit describes jurisdictions’ long-term needs on pages 21 – 24. Jurisdictions need to anticipate that the ability to obtain and link data on homeless deaths requires engagement with and commitment from the communities that produce the data, in addition to the organizations that manage the data. Through: 1) improved data standardization; 2) improved data quality; and 3) political will, these systems will continue to improve.

The Homeless Mortality Toolkit consists of four chapters and two appendixes.

Chapter 1 is entitled National Homeless Mortality Overview and consists of pages 5 – 11.

Chapter 2 is entitled How to Start a Local Homeless Mortality Data Report, which can be found on pages 12 – 25, and is largely used to describe numbers 1 – 6 above.

Chapter 3 is entitled Homeless Mortality Literature Review and begins on page 26 through page 29.

Chapter 4 is entitled Clinical Mortality Review: A Guide and can be found on pages 30 – 32.

Appendix A includes Clinical Mortality Review Example Materials (pages 33 – 35) and Appendix B includes Homeless Mortality Workgroup Member Resources (page 36) and lists various City/County Mortality Reports through 2020.

AB 271 and Education and Prevention Strategies

AB 271 states that Information gathered by the homeless death review committee and any recommendations made by the committee shall be used by the county to develop education and prevention strategies that will lead to improved coordination of services for the homeless population.

NHCHC references many homeless mortality reports completed by cities and counties nationwide before 2021 in Appendix B in the Homeless Mortality Toolkit, which can help California counties develop homeless mortality education and prevention strategies. Several of the reports in Appendix B were completed by California counties, including Santa Barbara, Santa Clara, and San Francisco (city/county).

Since 2022, several homeless mortality reports have been completed by California counties that are helping develop homeless mortality education and prevention strategies. They include:

Report on 2022 Orange County Homeless Deaths

The 2022 report states that the Homeless Death Review Committee reviewed and analyzed data related to the deaths that occurred in calendar year 2021 of PEH. The goal of the Committee was to utilize the data to uncover potential trends related to the causes of death for PEH that would lead to either service and/or policy recommendations that may help prevent future deaths among the homeless population. Click here to read the report.

Recent Trends in Mortality Rates and Causes of Death Among People Experiencing Homelessness in Los Angeles County: 2014 – 2022 May 2024

As stated in the report, the data presented demonstrate the urgent need for our systems of care and support for PEH in LA County to include a focus on preventing premature death. The recommendations at the end of the report grew out of a collaborative effort across multiple County entities to address the high and rising mortality rates in the homeless population. The HMPI workgroup has also developed a plan of action to address these recommendations. Click here to read the report.

Sacramento County 2022 Homeless Death Report

As stated in the report, the goal is to fuel the political and community will to find comprehensive solutions to end homelessness in our community and prevent the tragic deaths of our unhoused neighbors. Click here to read the report.

Alameda County 2022 Homeless Mortality Report

As stated in the report, their next steps involve further analyze these data, inform the development of future mortality reports and the coming dashboards, and make recommendations to reduce preventable deaths among people experiencing homelessness. Click here to read the report.

Together, the guidance promoted by the NHCHC and AB 271 can help California’s counties establish a Homeless Death Review Committee or further the development of similar committees to help fulfill AB 271 statewide.

It is time to realize more than ever, that for many people, living on the streets of California results in premature death. Too many people, including infants, take their last breath while homeless on the streets throughout California.

1 Comment

  1. Gregorio Barboza on June 11, 2024 at 8:46 am

    It is a good question to ask of our people experiencing homelessness population on the events causing death.
    The guidelines are also a good step forward as we will be quantifying data with the same eyes.

    On a minor note, we know that most providers and advocated the sympathetic to the cause, yet I would add that we go one step further and recommend people who are prolife.

    Sincerely,

    Gregorio Barboza

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