The homeless man arrived at the emergency room of a North Baltimore hospital on Monday, July 1.

He was middle-aged and partially paralyzed from a gunshot wound. A neurological injury left him with limited to no bladder control. He was addicted to drugs.

The man wanted a place to live. Sinai Hospital sent him away. It was 80 degrees outside.

He came back two days later. The urine in his catheter bag was dark. The bandages on his left foot were dirty. The hospital changed his bandages and sent him away. It was 87 degrees outside.

The next day was the Fourth of July. Across the city, people stepped out of air-conditioned homes into backyards where they grilled hotdogs and sipped cold drinks. The homeless man arrived at the hospital and was sent away. It was 93 degrees outside.

When he came back the following day, the man told the emergency room staff his urine smelled awful and it burned when he peed. Then he said something new. He said he had chest pains. Outside the emergency room that day, dark clouds menaced overhead, and the air was thick with an oppressive humidity. It was 97 degrees.

The hospital admitted him.

And once Sinai Hospital admitted him, it became almost impossible to get him to leave. This was not the outcome the hospital wanted.

LifeBridge Health, the parent company of Sinai Hospital, offers a wide range of services to prevent situations like this from happening. And yet more homeless people are coming to LifeBridge hospitals than ever before, according to Karen Jarrell, executive director of case management for Sinai Hospital and Grace Medical Center.

Jarrell’s childhood dream was to become a nurse and serve the less fortunate. Today, serving the less fortunate often means keeping a roof over their heads. She oversees dozens of social workers and case managers who visit patients after they’ve been discharged from the hospital. They go inside their homes, ask them about their medications and remind them about upcoming medical appointments. When there’s a problem, hospital workers try to solve it.

It can be as simple as paying someone’s utility bill, Jarrell said, or as complex as petitioning a judge for guardianship of a dementia patient. It can mean giving someone clothes or a new mattress, helping out with rent, or even footing the bill for a skilled nursing facility.

Jarrell said there was no easy way to explain the increase in homeless people at emergency rooms, and yet this crisis is unfolding across the country.

From 2011 to 2021, the estimated number of homeless people in America decreased slightly, but, according to federal data, the rate of homeless people walking, limping, and being wheeled into emergency rooms had more than doubled by the decade’s end.

Now, homelessness in America is once again on the rise, driven in part by the surging cost of housing. Landlords in the city and in Baltimore County file an average of more than 500 eviction lawsuits every day. Nearly 1,000 households are forcibly removed from their homes every month.

Addiction and mental illness add more layers of complication.

Generations ago, homeless people with mental illnesses might be sent to state-operated psychiatric hospitals. Maryland, following a national trend, shuttered many of them decades ago.

A history of substance abuse or a criminal record can bar people from assisted-living facilities or affordable housing. That’s a particular problem for Baltimore, the epicenter of an unprecedented overdose crisis.

According to one emergency medicine doctor in Baltimore, all of these problems — unaffordable housing, mental illness and drug addiction — are swirling together and presenting themselves at the one place you go when there’s seemingly nowhere else to turn: the emergency room.

The doctor, who does not work at a LifeBridge hospital, spoke on condition of anonymity out of fear of getting fired for speaking openly. The doctor said physicians and nurses will sometimes “stretch” a diagnosis to make sure a homeless person gets admitted.

The patient might have diabetes, sores on their feet, or some other problem that is not life-threatening, the doctor said. But left untreated, the diabetes will worsen, the sores will fester and a fixable problem will morph into a deadly one.

This gray area is when some patients become what staff call “social admits,” the doctor said, and put enormous strain on doctors and nurses.

Almost every day, a mentally ill homeless patient is cursing out staff members, the doctor said, and every week there is physical violence. Sometimes it’s a patient throwing food or pushing a doctor into a wall. Other weeks, it’s a nurse getting punched in the face.

At Sinai Hospital, staff spent weeks trying to find a place for the homeless man to live. His chest pain had subsided, and doctors who examined him determined that he didn’t need one of Sinai’s 480 beds — a prized resource in a hospital that is almost always full.

But hospitals can’t just discharge patients. Under Maryland law, hospitals are required to develop discharge plans, preferably in coordination with the patient. Yet the man refused to go to addiction treatment centers, and assisted living facilities refused to admit him because of his drug use.

When the staff found an organization that offered supportive housing for the homeless, the man refused to go. After multiple attempts to convince him to leave, the hospital decided it had only one option left.

On Monday afternoon, Aug. 12, the director of security for LifeBridge Health walked into the man’s room and dropped off some paperwork. The hospital was suing him, accusing him of trespassing. The details in this story are drawn from that lawsuit.

Suing a patient for trespassing is not unheard of. Earlier this year, MedStar Good Samaritan Hospital sued an 83-year-old man. A few months later, Johns Hopkins Hospital sued an 80-year-old woman. Neither case identified the patient as being homeless.

On Aug. 28, a Baltimore judge held a virtual hearing in Sinai’s case. The homeless man did not have an attorney, so he spoke for himself.

He said he was a grandfather. He mentioned his dead mother, the house she owned and a foreclosure. He talked about the time he woke up in the subway, surrounded by paramedics.

The homeless man acknowledged he had used fentanyl in the past, but only when he couldn’t get methadone. He uses methadone for pain management, he said, not because he’s addicted to drugs.

He uses a walker for short distances and a wheelchair for long ones. Sometimes, when he sits still, it feels like his heart is racing hard, like a sprinter’s. Every time he goes to sleep, he worries his heart will give out, and he won’t wake up. He said he needed more medical care.

An attorney for Sinai Hospital said the man’s health had improved since coming there — far beyond the point of needing a hospital bed. Tests were disproving what the man was claiming about his health. Staff had seen him walking around and smoking cigarettes.

“If he is not in need of medical care, then his discharge can be anywhere. He’s a homeless man,” the attorney said. “We certainly don’t want to discharge him to the street.”

But he was rejecting his only option for housing — a newly opened supportive housing facility in Baltimore.

The homeless man was distrustful. He’d never heard of it. Months earlier, an almost identical situation played out, he said. He came to Sinai for help, got treatment, and was discharged to a different facility. It didn’t work out.

“I was walking the streets day and night, unable to find anywhere to sleep,” he said.

When the hearing came to a close, the judge gave him a final opportunity to speak.

He told her he feared being homeless. He was afraid of the hunger, afraid of the dirtiness, afraid of the stench.

The judge weighed both sides. She found that the hospital had come up with a safe discharge plan, but she encouraged both parties to work towards an agreement. A week later, she authorized his removal.

“We are saddened over this situation and the complex challenges in the care of this individual, who stayed a number of weeks in the hospital beyond his medical needs and left following court orders,” LifeBridge said in a statement. “As outlined in legal filings, Sinai Hospital teams undertook exhaustive efforts to support this patient with multiple options for further care and housing, all of which were refused or denied.”

A spokesperson for the hospital said Sinai paid to send him to supportive housing.

Later, however, the homeless man returned to the streets.

This article has been updated to include details about Sinai sending the man to supportive services.