Hospital emergency room staffs call these patients frequent fliers. Many have chronic health problems worsened by living outside, in addition to substance abuse problems and untreated mental illness. Because their cases are so complicated they require expensive treatment and extra time from hospital staff.

But despite receiving repeated rounds of intensive and costly treatment, their health rarely improves when they return to the streets. They return to the hospital for more costly treatment again and again. Taxpayers and people with private insurance pay for this fruitless care, as hospitals shift costs onto them.

That's the reason to convince your editor to write about the health care costs of homelessness in your community.

Here is some advice on where to start, who to talk to, and how to organize your time to report this story. I've also included relevant research, an expert list, and tips I wish someone had given me.

Planning

While conceiving the idea to write about the health care costs of the chronically homeless, two aspects of this problem interested me most. First, what happens when a homeless person is hospitalized and has no place to finish recuperating after being discharged? What does the hospital do? Where do they go?

Second, I wanted to quantify the medical costs for one homeless individual. Malcolm Gladwell's piece called "Million-Dollar Murray" in the New Yorker inspired my story on Solis. Focusing on the immense costs of one individual effectively demonstrated the magnitude of the problem.

The work for a project like this can be divided into two broad categories:

1. Finding the people
2. Getting the numbers

Finding people: Plant seeds early and be patient

Finding homeless people to illustrate these scenarios takes time – lots of it. But it is possible.

Start by getting to know the advocates who work with the homeless daily at shelters, the county programs, food banks, etc. While it's important to have a good relationship with the directors of these programs to guarantee good access, the caseworkers on the frontlines are your key to finding people. They know individuals and stories, and if they're good their clients trust them. If the caseworker trusts you, they can be immensely helpful. They are very busy people, however, so call them once a week to kindly remind them of your project.

Hospital social workers can also be great resources, but tend to be more cautious about helping because of HIPAA, the federal patient privacy law. Meet with them and the hospital public relations officials early to explain your project and get their buy-in.

Be patient. It may take several weeks or months before anyone turns up. Several leads may fail. Let go of them if they aren't right. Another will turn up. In the meantime, get informed. If you're like I was – filing a story nearly every day – set aside a one or two hours each week to find relevant studies and interview experts.

Getting the numbers

In addition to the peer-reviewed studies and abstract quotes from experts, you need solid, local data. Keep this in mind while searching for people to write about. You need them to be entirely transparent.

Offering solutions

Many homeless advocates and medical experts point to supportive housing as a more cost-effective and humane solution to keeping chronically homeless people out of hospitals. Supportive housing combines affordable housing, case management and access to supportive services. Some programs don't require sobriety, and in response to criticism, they point to studies that show once housed, the addicts' costs to society greatly decrease.

Solis' case was a crude example of supportive housing. Solis lived in a dingy motel and a case manager checked on him regularly. While he didn't stop drinking entirely, he drank much less and didn't return to the hospital for two years after moving into the apartment.

Example of housing first

The San Francisco Public Health Department dedicates $30 million of its $1-billion budget to housing 1,000 chronically homeless frequent fliers. A study by the program by the University of California Berkeley's Goldman School of Public Policy found that San Francisco's investment in supportive housing decreased hospital use of 235 formerly chronically homeless people by more than 50 percent.

Example of interim care

Another large problem is the high, unnecessary costs associated with homeless people who have no place to recuperate after a hospitalization. They either stay in the hospital longer at the price of at least $1,000 a day, or they return to the streets, where they fail to heal and often return to the hospital with the same problem, sometimes within days.

The Sacramento Salvation Army's Interim Care Program is an example of a program that provides a place for homeless people to stay in the short-term while they recuperate from a hospitalization. Local hospitals helped fund the interim shelter because they realized it would save them money by reducing the extra days homeless people spent in the hospital because they had no other place to go.


Things I wish I had known from the start

Homeless people are hard to keep tabs on. Once you find someone willing to share his or her story, get information right away about their friends, where they live and hang out.
A homeless person may agree to work with you, but may soon ask you for things in return. Be clear about expectations and demands up-front.
Get a photographer involved early in the process, ideally from the first meeting.
Think multimedia from the beginning! Bring your audio recorder to every interview. Practice using the video camera or request a photographer comfortable with video so you can include that Web element. Brainstorm ways to involve the readers in the story through online comments, listing ways people can help and including maps and user-friendly graphics.
Without nagging, keep in close touch with the caseworkers and hospital social workers helping you find patients. Otherwise, they will forget about you.
Don't give yourself or your editors a deadline. You can't determine the timeline for this type of project. It took me seven months to complete.

Research

A landmark study led by Dennis Culhane at the University of Pennsylvania greatly shifted the federal government's philosophy on homelessness. There has been an increasing push to focus on the small number of people who consume the majority of resources. Culhane's study estimated that in 1999, chronically homeless people with several mental illnesses in New York City used about $40,000 per person in public services, such as emergency shelters, police, jail, mental health crisis centers and hospitals.