Blog Article: An Inter-agency approach to end deaths of homeless persons

The homeless are invisible in many communities; their deaths receive even less attention. An inter-agency review of homeless deaths, modeled after the Fetal and Infant Mortality Review process (FIMR), is an effective public health approach to understanding system gaps, and providing insight into the factors resulting in homelessness and ultimately death. This report describes the process to develop unique police-led reviews of homeless deaths in Indianapolis, Indiana, USA and recommendations for action to decrease these deaths. Additionally, the police can take the lead as part of a comprehensive problem solving effort.

The homeless are invisible in many communities; their deaths receive even less attention.  A inter-agency review of these deaths based on the fetal and infant mortality review (FIMR) process can provide insight into the homeless individual, system gaps that led to the death, and ultimately change systems to prevent future deaths (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008). In Indianapolis, Indiana, USA, law enforcement leads a team that includes community outreach workers, mental health professionals, local hospitals, emergency medical services, probation, the prosecutor’s office, the coroner’s office, the health department, and a local researcher. This short report describes this innovative initiative.

In January 2015, a national effort to count homeless individuals estimated over 564,000 people nationwide were homeless on any given night. Almost one-third of these individuals were found in locations not intended for human habitation and 23% of the total were chronically homeless (Henry, Shivji, de Sousa, Cohen, & Abt Associates Inc., 2015). However, research  suggests that the actual number of individuals experiencing homelessness at any given time is three to five times than this estimate (Sankari & Littlepage, 2015).

The Indianapolis Metropolitan Police Department (IMPD) took a progressive approach to working with the homeless population in Indianapolis when it created the Homelessness and Panhandling Unit (HPU). The HPU established cross-system partnerships in an effort to keep homeless individuals out of the criminal justice system and connect them with appropriate services (Hipple, 2016).

In March 2015, two fishermen found partially mummified human remains under an Indianapolis bridge. There were indications the remains were those of a homeless individual however no one from the HPU or its partner agencies knew this individual even after he was positively identified. This sentinel event raised the question, if no one from the HPU or its partner agencies had contact with him, were there other deceased homeless individuals unknown to officials? In fact, this event highlighted that there was no official count of homeless deaths for Indianapolis. Therefore, IMPD sought comprehensive data on homeless deaths which included reviewing all homeless deaths. Building on their existing partnerships, the HPU recruited a local researcher who could help facilitate the data collection and review process.

IMPD was no stranger to incident reviews (Klofas et al., 2006). For law enforcement, incident reviews often focus on specific crimes such as homicides, however, most homeless deaths are not the result of a criminal act though data are limited. Since homelessness is not a crime, the HPU needed to modify their review approach, choosing a public health model, FIMR.

FIMR is an evidence-based, action-oriented community process, continually assessing, monitoring, and working to improve service systems and community resources for women, infants, and families (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008). This standardized approach determines preventability, engages communities to take action and examines various morbidities and mortalities (Koontz, Buckley, & Ruderman, 2004; McDonnell, Strobino, Baldwin, Grason, & Misra, 2004; Nesheim et al., 2012).

The FIMR framework provides a systematic method to obtain information about homeless deaths beyond police and outreach records. FIMR includes consumer/family interviews to determine factors contributing to the individual’s life and death, which yields information about environmental aspects of the case. An inter-agency case review team (CRT) reviews each death to determine preventability and make recommendations for system change. These recommendations are sent to the community action team that is comprised of community leaders with the power to implement higher level proposals and implement recommendations.  Indianapolis partners concerned with homeless deaths supported using the FIMR process to examine causes and preventability of homeless deaths as it added data not part of the traditional crime incident review (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008).

Case review data also includes interviews with the deceased’s family and/or friends. Interviews provide a consumer/family perspective on the deceased’s situation and what may have led to homelessness and death. Data from medical records, police reports and other sources are compared to this consumer information. Plans are to contact neighbors and family members within one to three weeks after notification of the death.

Homeless death reviews occur in other jurisdictions in the United States such as Philadelphia and Sacramento although the reviews are not police-led like in Indianapolis. IMPD also sought an independent researcher to assist with comprehensive data collection, analysis, and facilitate the review meetings. The HPU introduced representatives from its existing partners to the FIMR process for reviewing homeless deaths.

Four goals were outlined for the reviews: prevent future deaths of homeless individuals, create a better flow of information; compile accurate data on homeless individual deaths; and create actionable recommendations. Prior to the review meeting, each agency provides relevant information, such as EMS transports, emergency department visits, medical and mental health history, housing information, veteran status, and any other relevant details about each decedent. A summary document for each case which was circulated. During the review meeting, information not available from official sources, such as social engagement, relationships, official/unofficial income is provided. This additional information facilitates identifying service gaps while not assigning blame. The homeless death CRT has met six times, reviewed 12 cases and has made recommendations. Some recommendations have already been addressed by the CRT and some recommendations need to be elevated to the community action team.

First, a common accidental cause of death of homeless individuals is exposure. Indianapolis winters can be harsh. The CRT team identified protocol modifications. Outreach workers and the HPU will be more assertive in locating homeless individuals during cold weather emergencies. For example, looking into tents for vulnerable individuals; prior protocol did not allow this to the protect the homeless individual’s privacy and the outreach worker’s safety. Moreover, part of homeless culture is ‘you are a sucker if you go in’ during extreme weather. The team discussed ways to respectfully provide outreach including, ‘mercy arrests,’ immediate detentions, or other creative options by IMPD to shelter vulnerable individuals temporarily and save lives.

Second, the CRT team identified the need for better coordination between area hospitals and outreach workers. One of the large metropolitan hospitals notifies outreach workers of homeless ‘frequent fliers.’ Outreach workers then engages with these individuals to try and get them into services. The death reviews revealed that this inter-agency communication between the hospital and outreach needs to be expanded to all area hospitals located both downtown and outside of the city center.

Third, in two cases clients agreed to go into inpatient detox but beds were not available. One client was approved for a detox bed but one not available immediately. That client died in the next 48 hours. Another died three days before scheduled to enter detox. Both deaths resulted from alcohol abuse during the waiting period. The CRT believes the deaths could have been prevented if beds had been immediately available. This issue requires a broader community response from the community action team.

Compiling accurate information on homeless deaths beyond those reviewed is an important next step along with establishing the community action team. Key to sustainability, the community action team is charged with developing creative solutions to improve services and resources for the homeless. Also participation is needed from the Veteran’s Administration, the health department, hospitals and elected officials. These individuals have the resources to address the CRT recommendations and system gaps identified in the review process. The community action team’s sponsor should be an important lead agency in Indianapolis. For example, in Baltimore, Maryland, the FIMR community action team is in the Mayor’s office, providing high level visibility and access to city agencies, assuring maximum impact. 

2016 started ominously for Indianapolis’s homeless population. On January 1st, two homeless individuals died. One individual was found by a friend at a homeless encampment and the other died at a local shelter. A total of four homeless individuals died by January 6th. Ranked one of the ten most violent cities in the United States in 2014 (Federal Bureau of Investigation, 2015), Indianapolis did not recorded its first criminal homicide until January 4, 2016. Homeless individuals, while omnipresent, are often invisible. Their deaths are no different.

Significant progress has been made and using FIMR as a public health approach is effective. One unanticipated benefit was achieved by the CRT. Partners were validated that in some cases, they did everything possible for the homeless. For front line workers who often see the worst, this is affirming and important to acknowledge.

Homelessness is a complex problem for many communities with insufficient data. While housing is a long-term issue, preventing deaths is not. Homeless person death reviews demonstrate there are steps that can prevent needless deaths. The FIMR process provides an inter-agency approach to understanding system gaps with insights into the factors that resulted in homelessness and ultimately death. It is an innovative approach to have the police lead the way and provides a structure for community solutions to address this public health problem. 

Federal Bureau of Investigation. (2015). Crime in the United States, 2014.   Retrieved from https://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2012/crime-in-the-u.s.-2012/violent-crime/aggravated-assault

Fetal and Infant Mortality Review Manual: A Guide for Communities. (2008).  (2nd ed.). Washington, DC: American College of Obstetricians and Gynecologists.

Henry, M., Shivji, A., de Sousa, T., Cohen, R., & Abt Associates Inc. (2015). The 2015 Annual Homeless Assessment Report (AHAR) to Congress: Point-in-Time estimates of homelessness. Retrieved from Washington, DC:

Hipple, N. K. (2016). Policing and homelessness: Using partnerships to address a cross system issue. Policing: A Journal of Policy and Practice. doi:doi:10.1093/police/paw010

Klofas, J. M., Hipple, N. K., McDevitt, J., Bynum, T. S., McGarrell, E. F., & Decker, S. H. (2006). Project Safe Neighborhoods: Strategic interventions crime incident reviews: Case Study 3 Project Safe Neighborhoods: Strategic Interventions. Washington, DC: U.S. Department of Justice, Office of Justice Programs.

Koontz, A. M., Buckley, K. A., & Ruderman, M. (2004). The evolution of fetal and infant mortality review as a public health strategy. Maternal and child health journal, 8(4), 195-203. doi:10.1023/B:MACI.0000047418.14086.fc

McDonnell, K. A., Strobino, D. M., Baldwin, K. M., Grason, H., & Misra, D. P. (2004). Comparison of FIMR programs with other perinatal systems initiatives. Maternal & Child Health Journal, 8(4), 231-238.

Nesheim, S., Taylor, A., Lampe, M. A., Kilmarx, P. H., Fitz Harris, L., Whitmore, S., . . . Mermin, J. (2012). A Framework for elimination of perinatal transmission of HIV in the United States. Pediatrics, 130(4), 738-744. doi:10.1542/peds.2012-0194

Sankari, A., & Littlepage, L. (2015). Many Families in Indiana Not Able to Find Shelter. Indianapolis, IN: Indiana University Public Policy Institute.