A state policy made it harder for families to find shelter. Research helped change the policy.

Physicians and policy makers usually work in separate worlds: those of medicine and government. But when a change in Massachusetts policy led to an unprecedented increase in the number of homeless families seeking shelter in the emergency department (ED), physicians at Boston Children’s Hospital set out to reverse that policy. What happened next shows that clinical experience and research can be powerful tools in addressing social determinants of health at a population level.

Chief complaint: homelessness

In 2012, a change in state policy required many families seeking emergency shelter from the state to show proof that they were staying in a place “not meant for human habitation.”  Although sleeping in a car, train station, or outdoors met the criteria, families were challenged to show proof of residing in such a place. After staying overnight in an ED, however, a family would have hospital documentation of their visit.

Soon after the rule went into effect, the number of families presenting to the ED without a medical complaint began to rise. As more families with nowhere else to go arrived, clinicians grew increasingly concerned about the children’s wellbeing.

“Often, families with infants and toddlers had to sit in the waiting area until 11 or 12 at night before we could put them in a room with a bed,” says Lois Lee, MD, MPH, senior associate of pediatrics in the Division of Emergency Medicine. She and her colleagues also worried about the children’s mental health, particularly those old enough to understand that their family had no safe place to go.

Research confirms: More families seeking temporary shelter in the ED

As clinical researchers, Lee and her colleagues knew that data could help bring attention to the issue. With that in mind, Amanda Stewart, MD, MPH, a Boston Children’s fellow at the time, took on the issue.

In a retrospective study comparing the number of ED visits by children experiencing homelessness before and after the policy change, she found that:

• The number of children presenting in Boston Children’s ED for homelessness more than quadrupled between 2012 and 2016.
• State-based insurers covered 89 percent of the cost of these ED visits, which were significantly higher than the cost of providing state-run shelter.

Translating research into advocacy

With this data in hand, it was time to bring the issue to state policymakers. For this, they sought help from Boston Children’s Office of Government Relations and community organizations, including the Massachusetts Coalition for the Homeless and Massachusetts Law Reform Institute. Soon they had knowledgeable partners helping them navigate the legislative process.

“Our community partners helped us identify key stakeholders and tailor our message to specific committees,” says Stewart. For instance:

• The Joint Committee on Children, Families, and Persons with Disabilities would be most concerned about the impact on children of spending a night in the ED when shelter was unavailable.
• The Joint Committee on Ways and Means would be interested the health care costs of preventable ED visits.

Following written and oral testimony from families experiencing homelessness, local housing advocates, and Boston Children’s clinicians, the Massachusetts legislature overturned the shelter eligibility requirement in 2019. Stewart, Lee, and several collaborators described their use of research to advocate for the policy change in Pediatrics.

Continuing to advocate for families

Despite their success, the clinicians’ work was far from complete. Families continued to present to the ED for shelter, referred by agencies that hadn’t heard of the legislative reversal. The team realized it was time to shift its efforts to raising awareness and increasing options for families. In the years since 2019, the work has continued and evolved to meet the needs of a growing number of new immigrant families seeking shelter.

The experience at Boston Children’s demonstrates how research — traditionally intended for clinical and academic audiences — can be a powerful tool for change on a broad scale. However, to be successful, clinicians need to take a long view. Not only does policy work often take years of effort, but housing instability continues to impact the health of thousands of families.

Learn more about the Office of Government Relations.