HomeMy WebLinkAboutalameda-county-homeless-mortality-report-cy2021
Artwork by Jeremy Beebe
Alameda County
2021 Homeless
Mortality Report
Alameda County Health Care Services Agency
Health Care for the Homeless Program
Community Assessment, Planning, and Evaluation
Alameda County Homeless Mortality Report 2021
2
Alameda County Health Care Services Agency
Colleen Chawla, Director
Nicholas Moss, MD MPH, Health Officer
HCSA Office of Homeless Care and Coordination
Kerry Abbott, Director
Lucy Kasdin, Director, Alameda County Health Care for the Homeless Program
HCSA Public Health Department
Kimi Watkins-Tartt, Director
Chuck McKetney, Interim Director, Community Assessment, Planning, and Evaluation
Acknowledgements
This report was produced by the Alameda County Health Care Services Agency’s Health Care for the
Homeless (HCH) program and Community Assessment, Planning, and Evaluation (CAPE). Matt Beyers
and Yilak Fantaye, CAPE, provided epidemiological direction and guidance. David Modersbach, HCH,
provided analysis, content, and writing. Special thanks to Wilma Lozada, HCH, for records review, and
all of the community partners who supported this effort.
Alameda County Health Care for the Homeless
1404 Franklin Street #200
Oakland CA 94601
510-891-8950
www.achch.org
Alameda County Health Care for the Homeless program is supported by the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $4,064,392 and other non-
federal funding sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor
an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit www.HRSA.gov.
Original Cover Art by Jeremy Beebe “psycopomps #3 mixed media on canvas 2020-2023.” Jeremy
Beebe is a multi-media artist musician who creates art reflecting the lived experience of homeless-
ness. He currently lives alternatively-housed with his dog Terry “Bozo” Bozzio in West Oakland. He
believes that everyone is artist and calls on all to recognize the value of artwork in our lives.
This report is available online at https://www.achch.org/alameda-county-homeless-mortality.html
Alameda County Homeless Mortality Report 2021
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Contents
Executive Summary .................................................................................................................................. 4
Introduction .............................................................................................................................................. 7
Methods .................................................................................................................................................... 8
All Deaths: Characteristics of Deaths...................................................................................................... 11
Homeless Deaths by Region of Alameda County ................................................................................... 18
Homeless Deaths Outside of Alameda County ................................................................................... 18
Berkeley/Albany.................................................................................................................................. 18
Oakland/Emeryville ............................................................................................................................ 19
Mid-County (Hayward, Alameda, San Leandro, San Lorenzo, Castro Valley) .................................... 20
South County (Fremont, Newark, Union City) .................................................................................... 21
Tri-Valley (Livermore, Pleasanton, Dublin) ......................................................................................... 22
Shelter and Encampment Deaths ....................................................................................................... 23
Vehicle Dweller Deaths ....................................................................................................................... 25
Causes of Death of People Experiencing Homelessness in Alameda County ........................................ 26
Underlying Cause of Death: Drug Overdose ....................................................................................... 26
Category of Death: Acute and Chronic Medical Conditions ............................................................... 32
Category of Death: Accidental Death ................................................................................................. 33
Underlying Cause of Death: Homicide ................................................................................................ 35
Underlying Cause of Death: Suicide ................................................................................................... 36
Underlying Cause of Death: R99 – Ill-Defined or Unknown Cause of Death ...................................... 37
Mortality Rates, Premature Mortality Rates, and Comparisons to the General Population ............. 38
Services Utilization and Homeless Mortality .......................................................................................... 41
Homelessness System Implications and Next Steps ............................................................................... 42
Appendix ................................................................................................................................................. 43
Alameda County Homeless Mortality Report 2021
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Executive Summary
A responsible and just community must work to be closely aware of the deaths of all its members, strive
to learn from those deaths, implement policies and practices to reduce preventable deaths, and work
to reduce the harm that preventable deaths create for families, friends, caregivers, and the community.
A just community will look at the places and moments of death and ensure that people who die do not
die alone and experience death in as peaceful a manner as possible.
The Alameda County Health Care Services Agency’s Health Care for the Homeless (HCH) program and
Public Health Department Community Assessment, Planning, and Evaluation (CAPE) unit carried out
Alameda County’s first-ever homeless mortality report in 2020 and are striving to carry out this report
on an annual basis.
This report is based on identification of homeless deaths through data matching across homeless ser-
vices utilization lists, community reporters and California Comprehensive Death File (CCDF) records in
the California Vital Records Business Information System.
Because of the methods used, Alameda County’s homeless death numbers will appear higher than
those of other localities that rely solely on Medical Examiner/Coroner’s reports of homeless deaths.
Key Findings in the 2021 Alameda County Homeless Mortality Report
The number of annual homeless deaths grew considerably larger between 2018 and 2020 and re-
mained at a very high level in 2021. Between 2018 and 2021, 1,157 Alameda County residents died
while experiencing homelessness.
Housing Status at Time of Death
Known to be
homeless at
years of death, but
housed at time of
years of death, but un-
known housing status
2018 195 57 189
2019 246 91 198
Total 1,157 417 744
Mortality rate: The age-adjusted mortality rate for people experiencing homelessness in Alameda
County in 2021 was 5.8 times that of the general population of Alameda County. For all causes of
death, mortality rates are many times higher for people experiencing homelessness than the general
population.
Unattended deaths: Sixty-six percent (229 out of 346) of all homeless deaths took place outside of a
medical setting (i.e., hospital or nursing facility), occurring on streets/sidewalks, outdoors, in vehicles,
encampments, shelters, other’s residences and other locations. Half of homeless acute/chronic dis-
ease-related deaths (77 out of 153) occurred in “unattended” settings.
Alameda County Homeless Mortality Report 2021
5
Disparities by race/ethnicity and gender: African American/Black persons represent 41% of total
homeless deaths, compared to 19% of general population deaths and 11% of the general population.
Men represent 75.6% of homeless deaths, compared to 52.7% of general population deaths.
Characteristics of Homeless 2021 Deaths
• Drug overdose: 30.6% of homeless deaths in 2021
(106) were directly due to drug overdoses of uninten-
tional or undetermined intent (hereafter called drug
overdose). The number of overdoses among people
experiencing homelessness continued a sharp rise.
Sixty-seven percent of drug overdose deaths took
place in outdoor settings. People experiencing home-
lessness have 50 times the drug overdose death rate
of the general population.
• Acute/chronic medical conditions: Forty-four per-
cent of the homeless deaths in 2021 (153) were due
to acute/chronic medical conditions, led by heart and
cardiovascular disease, and followed by cancer,
COVID-19, liver disease, cerebrovascular disease, respiratory disease, and others. Half of
acute/chronic disease-related deaths occurred outside of medical/clinical settings.
• Accidental injuries accounted for 31 (9%) homeless deaths, the large majority being pedestrians and
cyclists hit by automobiles, followed by falls and struck by trains. Homeless pedestrians/bicyclists
are 28 times more likely to be killed by cars than the general population.
• Homicide accounted for 22 (6%) deaths of people experiencing homelessness, mostly due to shoot-
ings and stabbings taking place in street and outdoors. The death rate for homicide among people
experiencing homelessness is 23 times than that of the general population.
• Suicide: Nine people experiencing homelessness took their own lives in 2021, a rate ten times that
of the general population.
• Shelter residents: At least 40 persons residing in homeless shelters died in 2021. Seventy-eight per-
cent died of acute/chronic diseases, 17% of drug overdoses, and 5% by suicide or accident. The per-
centage of shelter overdoses declined from 25% to 17% in 2021.
• Encampments: At least 32 people died in homeless encampments in 2021. Sixty percent died of drug
overdoses, 13% of acute/chronic diseases, 6% of homicide, and 6% died of other causes including
fire and exposure, and 16% undetermined by coroner.
• Vehicle dwellers: Some 34 persons were reported as having died inside their vehicle of residence in
2021. This is in addition to those who might have died in facilities but lived in their vehicle. Half died
of drug overdoses, and the other half by acute/chronic disease and one by suicide.
• COVID-19: COVID-19 was cause of death for nine persons experiencing homelessness in 2021. There
were no shelter resident COVID-19 deaths in 2021. Still COVID-19 death rate for people experiencing
homelessness was 2.6 times that of the general population. COVID-19 deaths took place primarily
in hospitals among people staying place to place, living in motels and in an encampment.
35
61
94 106
2018 2019 2020 2021
Homeless Drug Overdose Deaths 2018-2021
Alameda County Homeless Mortality Report 2021
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Next Steps
This Alameda County homeless mortality report focuses on data and accurately enumerates deaths
among our unhoused communities. To advance this work, the County of Alameda is convening a count-
ywide Homeless Mortality Review Team to further analyze these data, inform the development of fu-
ture mortality reports, and make recommendations to reduce preventable deaths among people ex-
periencing homelessness. If you or your organization are interested in learning more about the Home-
less Mortality Review Team, please reach out to achch@acgov.org.
Artwork by Jeremy Beebe “Caduceus of Wood Street ” 2022
Alameda County Homeless Mortality Report 2021
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Introduction
The experience of homelessness has well-documented, long-term consequences on people’s health
and well-being.
A responsible and just community must work to be closely aware of the deaths of all its members, strive
to learn from those deaths, implement policies and practices to reduce preventable deaths, and work
to reduce the harm that preventable deaths create for families, friends, caregivers, and the community.
A just community will look at the places and moments of death and ensure that people who die do not
die alone and experience death in as peaceful a manner as possible.
This review marks the second Alameda County effort to report and review of the deaths of County
residents experiencing homelessness. This initiative is joint work by the Alameda County Health Care
Services Agency’s Health Care for the Homeless program the Public Health Department’s Community
Assessment, Planning, and Evaluation program. It also reflects collaboration and partnership with nu-
merous community, city, and County partners.
This CY2021 annual report builds on a retrospective 2018-2020 Homeless Mortality Report and will be
followed by regular mortality reports and review processes that can grow to include the multiple agen-
cies, as well as the community of providers and residents who support the health and wellbeing of
people experiencing homelessness.
Alameda County is working to convene a countywide Homeless Mortality Review Team to work on an
ongoing basis to further analyze mortality data, inform the development of future mortality reports,
and make recommendations to reduce preventable deaths among people experiencing homelessness
Across the country, localities are increasingly working to carry out homeless mortality reporting and
review, to bring attention and analysis on a national level to the impacts of homelessness on health
and mortality and improve health care interventions as well as end-of-life services for the most vulner-
able in our society.
We are proud to be part of the National Health Care for the Homeless Council and the Homeless Mor-
tality Working Group which has been instrumental in this effort, and you can review national efforts at
www.nhchc.org/homeless-mortality.
Alameda County Homeless Mortality Report 2021
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Methods
All local health jurisdictions across the country have systems for review and determination of death,
generally reporting death data to their state health department. Generally, a county or local jurisdiction
will have one of two structures for evaluating deaths.
1. Medical examiner: County-appointed office led by a physician, carrying out a variety of mortality-
related services including analysis and review of deaths in a community.
2. Coroner: Law enforcement-based office, carrying out investigation of suspicious or unattended
deaths under supervision of Sheriff, a position held or appointed by an elected coroner/sheriff, with
no medical training requirements.
Alameda County has a Coroner’s office, with the coroner appointed and supervised by the Alameda
County Sheriff’s Office. The Coroner’s office generally only investigates and reports deaths that are
either unattended (taking place outside of a hospital or other clinical setting such as nursing facility) or
suspicious in nature. Additionally, the Coroner may not have access to the records of homeless deaths
by “natural” causes taking place in a hospital or medical facility. Most communities that carry out a
homeless mortality review do so with death data provided through cooperation and efforts of their
local Coroner or Medical Examiner. See the Appendix for a list of recent homeless mortality reports
from neighboring jurisdictions.
Alameda County HCSA’s approach to identifying homeless deaths utilizes a comprehensive range of
data sources traditionally not used for mortality reviews. We used the state’s California Comprehensive
Death Files from the Vital Records Business Information System (VRBIS) alongside multiple countywide
sources of homelessness-related data and mortality reports to arrive at an accurate and comprehen-
sive accounting of the deaths of county residents who have died in homelessness. By applying this
approach, a greater number of homeless deaths are identified.
Our method of determining homeless deaths was based on cross-systems data matching to determine
homelessness at time of death, evaluating cause of death, and comparing mortality rates across the
Alameda County general population and people dying in homelessness. In the following pages, we
break out total homeless deaths by geography and place, decedent demographics, and underlying
health conditions and cause of death.
Determining Homelessness at Time of Death
• Data matching: We used local homeless services utilization data to build a master list of people
known to have experienced homelessness in the past five years.
o Alameda County Social Health Information Exchange (SHIE): 15,741 names of persons who
were provided homeless or safety net health care services. This includes persons in the Home-
less Management Information System who were provided with homeless/housing support ser-
vices.
o Health Care for the Homeless utilization: 28,529 utilizers of HCH services between 2017 and
2021.
o We compared these lists of people known to be experiencing homelessness against the Califor-
nia Comprehensive Death Files to find matches.
• California Comprehensive Deaths Files (CCDF) review: Staff carefully reviewed all state death rec-
ords data for Alameda County deaths, for information on homeless status inputted by physicians,
medical examiners/coroner, or funeral home staff. For example, the words “homeless,”
Alameda County Homeless Mortality Report 2021
9
“encampment,” “transient,” etc., may indicate homelessness. We have led efforts at the California
Department of Public Health to include homelessness status as a field in death records.
• Community reporters: We received reports of homeless deaths from:
o Coroner’s office: 155 names of decedents labeled as transient (not all homeless).
o UCSF HOPE/HOME study: 21 deaths in 2021 registered in an ongoing study of aging Oaklanders
experiencing homelessness.
o Community reporters: 32 deaths reported to ACHCH in 2021 through community reports and
the ACHCH Homeless Mortality Reporting form.
o Lists of known homeless deaths reported to us by ACHCH contracted Street Health, Lifelong
Trust Clinic, and other health care providers.
o Review of media reports of homeless deaths.
• Determining homeless status: ACHCH and CAPE staff carried out close analysis of each possible
homeless death, including review of HMIS notes and records where possible, and used the HUD
definition of “literally homeless” to determine housing status at time of death, producing the fol-
lowing categories.
o Homeless at time of death
We used the HUD definition of homelessness, and included persons known to be experienc-
ing homelessness but who were hospitalized or in a nursing facility at time of death.
o Recent (less than five years) history of homelessness, but housed at time of death
This includes persons with recent history of homelessness but known to be housed in per-
manent supportive housing or in other permanent housing at time of death.
o Recent (less than five years) history of homelessness, unknown housing status at time of
death
This includes persons who may have been doubled-up, precariously housed or permanently
housed or even literally homeless at time of death, but for whom not enough information
was available to determine homeless status.
Evaluating Cause of Death
• Underlying cause of death
o Staff reviewed the ICD-10 codes, the underlying cause of death diagnosis code, in the underlying
cause of death field in the CCDF and categorized them.
• Location of death
o Staff evaluated the CCDF information for location of injury or location of death and determined
location of death for people experiencing homelessness, such as streets, encampment, hospital,
nursing facility, vehicle, another’s residence, shelter, or outdoors, based on CCDF information.
• City of last known residence
o Staff evaluated CCDF, SHIE, and HCH data to determine the city where decedent was last known
to be living, as in CCDF city of death is often attributed to a hospital or nursing facility.
• Contributing causes of death
o Staff reviewed CCDF data to analyze the contributing causes of death (such as alcohol, drug use,
or mental illness) which may or may not have been input into the records via the state’s Elec-
tronic Death Registration System as reflected in the CCDF.
Alameda County Homeless Mortality Report 2021
10
Death and Mortality Rates
For this homeless mortality report, we used the same categories of underlying cause of death to calcu-
late mortality rates among both those experiencing homelessness and the full Alameda County popu-
lation. To accurately calculate the age-adjusted mortality rate, the population-years at risk is needed
as a denominator. The mortality rate for persons experiencing homelessness is based on a denominator
of 9,490 people on average experiencing homelessness in Alameda County per day in 2021. This num-
ber was arrived at through linear regression of three Point In Time Counts carried out in Alameda
County in 2017, 2019 and 2022. This estimated number of people experiencing homelessness on an
average day in 2021 – 9,490 persons – was used to generate overall and cause-specific mortality rates
among people experiencing homelessness and to directly compare to the general population of Ala-
meda County during that period. A mortality rate ratio divides and compares the two age-adjusted
rates.
What Could Help Refine this Report?
By using more data matching in future efforts, we can get a better idea of who is and isn’t utilizing
systems and learn more about mortality among certain segments of the population.
• Additional Coroner’s data: We were not able to systematically access some Alameda County Cor-
oner’s Office data and notes (for example toxicology reports on overdoses) for deaths investigated
by that office.
• Additional homeless services utilization data: It is critical to review utilization of various homeless-
ness services to get a better idea of circumstances leading to death, and opportunities to prevent
death. Examples of utilization data sources we want to incorporate in the future are itemized in
Chapter 10.
• More accuracy in determining homeless/housing status: We will work to develop better data-
matching in HMIS data to more accurately determine last-known housing status.
Our goal is to continue to work to bring together the above providers and data systems to enable better
homeless mortality reporting and utilization analysis in the future.
Alameda County Homeless Mortality Report 2021
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All Deaths: Characteristics of Deaths
In 2021, 346 people died while experiencing homelessness in Alameda County. An additional 146 per-
sons known to be housed after the recent experience of homelessness died during this period. The
analysis also revealed that some 167 persons with recent experience of homelessness, but with un-
known housing status at the time of death, died.
Homeless Deaths Housing Status at Time of Death, 2021
People determined to have died while experiencing literal
homelessness
346
People with recent (<5 year) experience of homelessness but
determined to be housed at the time of death
146
Persons with recent (<5 year) experience of homelessness but
with unknown housing status at time of death
167
Most of the following analysis of homeless causes of death will be focused on the 346 persons who
were determined to have died in homelessness in Alameda County in 2021.
The 346 deaths of Alameda County residents experiencing homelessness equal an age-adjusted home-
less death rate of 3,366.2 per 100,000, compared to the general population of Alameda County
(572.1/100,000). This means that persons experiencing homelessness have an age-adjusted mortality
rate ratio 5.8 times that of the general population.
The number of homeless deaths increased by 88.7% from 2018 to 2021.
Homeless Deaths by Housing Status, Alameda County, 2018-2021
195
246
368
346
57
91 102
167189
198 211
146
2018 2019 2020 2021
Known to be
homeless at time of
death
Homeless within 5
years of death, but
housed at time of
death
Homeless within 5
years of death, but
unknown housing
status at death
Alameda County Homeless Mortality Report 2021
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Homeless Deaths by Region of Last Residence
Berkeley/ Oakland/
Hayward, Alameda,
San Leandro, San
Lorenzo, Castro
South County:
Fremont,
Newark,
Tri-Valley:
Dublin,
Pleasanton,
2018 19 102 49 16 9
2019 18 141 55 18 14
2020 25 215 84 26 17
2021 24 208 55 31 15
Total 86 666 243 91 55
Homeless Deaths by City of Last Residence
In addition to the 346 Alameda County homeless deaths, 15 Alameda County residents experiencing
homelessness died in California counties outside of Alameda County. These deaths are evaluated in the
Deaths by Region section of this report.
Homeless Deaths by City of Last
Known Residence
Oakland 204 59.0%
Hayward 35 10.1%
Berkeley 24 6.9%
Fremont 19 5.5%
Unknown 13 3.8%
Livermore 9 2.6%
San Leandro 8 2.3%
Alameda 8 2.3%
Union City 6 1.7%
Newark 6 1.7%
Pleasanton 5 1.4%
Emeryville 4 1.2%
Castro Valley 2 0.6%
San Lorenzo 2 0.6%
Dublin 1 0.3%
Total 346 100.0%
Alameda County
San Francisco 3
San Jose 2
Santa Barbara 1
Pittsburg 1
Palo Alto 1
San Rafael 1
Modesto 1
Los Angeles 1
Lancaster 1
Fairfield 1
Walnut Creek 1
Richmond 1
Total 15
Categories of Causes of Death
Below are the general causes of death for the 346 persons who passed away while experiencing home-
lessness in Alameda County in 2021. Each of these categories of death will be discussed in further detail
in later chapters.
Alameda County Homeless Mortality Report 2021
13
Categories of Causes of Death, 2018-2021
2018 2019 2020 2021 2018-2021 Percentage
Acute/chronic disease 95 114 178 153 540 46.8%
Accidental injury 21 27 34 31 113 9.8%
Homicide 16 15 28 22 81 7.0%
Suicide 10 9 16 9 44 3.8%
Total 195 246 368 346 1,155 100.0%
Underlying Causes of Death
Underlying cause of death is a manner of classifying the specific cause of death type, including catego-
ries of disease and accident type. Below is the underlying cause of death for the 809 persons who
passed away in homelessness 2018-2021. Note that R99 is an ICD-10 mortality code meaning an “ill-
defined and unknown cause of mortality”; we designate this as Unknown (R99) throughout the text.
Underlying Causes of Death, 2018-2021
Unintentional overdose 35 61 95 104 295 25.5%
Heart disease 40 34 42 54 170 14.7%
All other diseases 17 24 43 35 119 10.3%
Homicide 16 15 28 22 81 7.0%
Cancer (malignant neoplasms) 15 18 16 16 65 5.6%
Chronic liver disease/cirrhosis 11 13 23 8 55 4.8%
All other unintentional injuries 9 11 14 17 51 4.4%
Suicide 10 9 16 9 44 3.8%
Pedestrian or bike crash 7 11 15 9 42 3.6%
Unknown (R99) 4 5 8 20 37 3.2%
Cerebrovascular disease 4 7 13 4 28 2.4%
CLRD (chronic lower respiratory disease) 2 9 10 7 28 2.4%
Sequelae of drug abuse & dependence 5 8 5 5 23 2.0%
Other communicable diseases 1 4 11 4 20 1.7%
Struck by train 4 4 4 4 16 1.4%
Diabetes, metabolic 3 1 7 4 15 1.3%
COVID-19 0 0 6 9 15 1.3%
Hypertensive renal disease/essential hypertension 1 3 3 6 13 1.1%
Alcohol overdose 5 4 3 0 12 1.0%
Sequelae of alcohol abuse/dependence 4 3 2 2 11 1.0%
HIV 1 1 3 5 10 0.9%
Exposure 1 1 1 1 4 0.3%
Alzheimer’s, Parkinson’s, and other dementias 0 0 0 1 1 0.1%
Alameda County Homeless Mortality Report 2021
14
Demographics of Homeless Deaths
Sex of Homeless Deaths
• The county population is 49% male and 51% fe-
male (2021). County general population deaths in
2021 were 52.7% male, 47.3% female.
• The population of people experiencing homeless-
ness is estimated to be 62% male and 37% female
and 1% transgender (2022 PITC). Homeless 2021
deaths were 76% male and 24% female.
• We were unable to categorize homeless deaths
by sexual orientation or gender identity as this in-
formation is unavailable in death records.
Race/Ethnicity of Homeless Deaths
• The county population is 10% African Ameri-
can/Black; 39% White; 32% Asian; 23% His-
panic/Latino; and 19% all other. 2021 county pop-
ulation deaths were 19% African American/Black;
43% White; 21% Asian; 14% Hispanic/Latino; 3%
all other or unknown.
• The population of people experiencing homeless-
ness is 43% African American/Black; 39% White;
25% Hispanic/Latino; 5% Asian, and 14% all other
(2022 PITC). Homeless deaths by race are in the
chart.
Age of Homeless Deaths
The average age of death of people experiencing homelessness in 2021 was 51.7 years; the Alameda
County general population average age of death of was 72.7 years. Average age of death includes ba-
bies and youth, who would normally not be homeless, and pulls down the general population average
age of death.
2 6
36
59 69 60
7
0-17 18-24 25-34 35-44 45-54 55-64 65+Unknown
All Other
Races/
Unknown
26
7.5%
Asian
12
3.5%
Hispanic/
Latino
64
18.5%
White
103
29.8%
African
American/
Black
141
40.8%
Male
263
76.0%
Female
83
24.0%
Age Group of Homeless Deaths, Alameda County, 2021
Alameda County Homeless Mortality Report 2021
15
Deaths by Month and Season
Although between 2018-2020 there was no clear correlation in deaths by month, in 2021 there were
more deaths in colder months from November to April (54%) than warmer months from May to Octo-
ber (46%), but with a peak of deaths in August.
Month of Homeless Deaths, Alameda County, 2021
Unattended Deaths
Of the 346 deaths of people experiencing homelessness in Alameda County in 2021, 117 people (33.6%)
died in a hospital or nursing facility. This means that overall, 229 homeless deaths (66.2%) occurred
either unattended or with first responders in the case of traumatic death (accident, homicide, suicide,
overdose). Below are unattended homeless deaths by cause of death.
Cause of Death, Unattended Homeless Deaths, 2021
Drug overdose 94 41.0%
Heart disease 33 14.4%
All other diseases 18 7.9%
Unknown (R99) 16 7.0%
Homicide 15 6.6%
Pedestrian or bike crash, unintentional or undetermined intent 7 3.1%
All other injuries 7 3.1%
Suicide 6 2.6%
Cancer (malignant neoplasms) 6 2.6%
Diabetes mellitus 4 1.7%
CLRD 4 1.7%
Hypertensive renal disease/essential hypertension 4 1.7%
Unintentional or undetermined intent pedestrian struck by train 4 1.7%
Cerebrovascular disease 2 0.9%
30 29
34
30 31
23
26
36
18
25
30
34
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Alameda County Homeless Mortality Report 2021
16
Total 229 100.0%
Note: The above chart includes deaths by injury, homicide/suicide, or overdose that occurred in the field, but were
pronounced dead at emergency departments or hospitals.
Location of Unattended Homeless Deaths by Category of Cause of Death 2021
Death Location Percent-
Substance
Abuse
and
Acute/
Chronic Acci-Hom-Sui-Unknown
Percentage of all deaths 42% 34% 8% 7% 2% 7%
Street/sidewalk 62 27% 29% 16% 16% 80% 20% 38%
Vehicle 34 15% 18% 20% 0% 0% 20% 6%
Other’s residence 28 12% 13% 18% 0% 7% 20% 0%
Encampment 27 12% 17% 5% 11% 7% 0% 25%
Outdoors 25 11% 11% 4% 26% 7% 0% 31%
Shelter 23 10% 6% 22% 0% 0% 0% 0%
Motel 19 8% 6% 14% 5% 0% 20% 0%
Road accident 9 4% 0% 0% 42% 0% 20% 0%
Total 227 100% 100% 100% 100% 100% 100% 100%
Alameda County Homeless Mortality Report 2021
17
Unattended Homeless Deaths by Various Demographics, 2021
Count Percentage
Total 227 100.0%
Region of county
Sex
Race/ethnicity
Age
Average age at death 52.0
Services noted in HMIS
Alameda County Homeless Mortality Report 2021
18
Homeless Deaths by Region of Alameda County
Homeless Deaths Outside of Alameda County
By comparing homeless services utilization data from Alameda County against the CCDF data, we re-
viewed deaths of 14 people experiencing homelessness who were known to be Alameda County resi-
dents and receiving services in Alameda County, but who died in homelessness in other California coun-
ties in 2021. For example, a person known to be an Alameda County resident experiencing homeless-
ness was found dead in San Francisco on the end of the BART line.
Berkeley/Albany
In 2021, 24 people experiencing homelessness died with their last known residence in Berkeley and
Albany.
Homeless Berkeley-Albany Deaths by Year
2018 19
2019 18
2020 25
2021 24
Homeless Berkeley-Albany Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of
death/injury
Alameda County Homeless Mortality Report 2021
19
Oakland/Emeryville
In 2021, 208 people experiencing homelessness died with their last known residence in Oakland or
Emeryville.
Homeless Oakland-Emeryville Deaths by Year
2018 102
2019 141
2020 216
2021 208
Homeless Oakland-Emeryville Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of death/
injury
Alameda County Homeless Mortality Report 2021
20
Mid-County (Hayward, Alameda, San Leandro, San Lorenzo, Castro Valley)
In 2021, 55 people experiencing homelessness died with their last known residence in Hayward, Ala-
meda, San Leandro, San Lorenzo, or Castro Valley.
Homeless Mid-County Deaths by Year
Year Count
2018 49
2019 55
2020 84
2021 55
Homeless Mid County Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of
death/injury
Alameda County Homeless Mortality Report 2021
21
South County (Fremont, Newark, Union City)
In 2021, 31 people experiencing homelessness died with their city of last known residence in Fremont,
Newark, or Union City.
Homeless South County Deaths by Year
2018 16
2019 18
2020 26
2021 31
Homeless South County Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of
death/injury
Alameda County Homeless Mortality Report 2021
22
Tri-Valley (Livermore, Pleasanton, Dublin)
In 2021, 15 people experiencing homelessness died with a city of last known residence of Livermore,
Pleasanton, or Dublin.
Homeless Tri-Valley Deaths by Year
2018 9
2019 14
2020 17
2021 15
Homeless Deaths in Tri-Valley by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of death/injury
Alameda County Homeless Mortality Report 2021
23
Shelter and Encampment Deaths
Shelter Residents
Analysis of CCDF records, HMIS notes, and community reports determined that in 2021, 40 persons
known to be living in homeless shelters or programs died in Alameda County. 25 (62.5%) of these
deaths occurred in Project Roomkey/Safer Ground housing which housed medically fragile and aging
people experiencing homelessness. There were no shelter resident deaths due to COVID-19. 53% of
shelter deaths occurred on site, 37% in medical facilities and the remainder in motel, vehicle or outside.
Homeless Shelter Resident Deaths by Year
2018 12
2019 23
2020 37
2021 40
Homeless Shelter Resident Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Unattended deaths
Location of
death/injury
Alameda County Homeless Mortality Report 2021
24
Encampment Resident Deaths
We were not able to accurately determine mortality outcomes among those who were living in unshel-
tered/encampment settings as it was frequently not feasible to determine people’s exact homeless
location at time of death. In CCDF notes, descriptors for unsheltered settings such as camp, tents,
streets were used interchangeably, and encampments were infrequently entered as a decedent’s home
address. However, we reviewed the deaths of 27 Alameda County residents who were specified in CCDF
as having died at an encampment setting in 2021.
Homeless Encampment Resident Deaths by Year
2018 12
2019 12
2020 25
2021 27
Homeless Encampment Resident Deaths by Various Demographics, 2021
Count Percentage
City/place
Sex
Race/ethnicity
Cause of death
Alameda County Homeless Mortality Report 2021
25
Vehicle Dweller Deaths
Through review of CCDF records, HMIS notes, and community reports we determined that in 2021, 34
persons died in vehicles in which they were sheltered at time of death. This number is only of those
who were found in a vehicle and does not include those who died elsewhere and who had been living
in a vehicle. All vehicle dweller deaths were found in their vehicles, and as such were all unattended
deaths.
Demographics Count Percentage
Total 104
Region of county
Sex
Race/ethnicity
Age
Average age of death 52.6
Services noted in
HMIS
Alameda County Homeless Mortality Report 2021
26
Causes of Death of People Experiencing Homelessness in Alameda County
In the following section we will review the categories of death among people experiencing homeless-
ness who died in 2021. Categories of death is the large grouping of deaths by categories, including
Acute or Chronic Diseases, Substance Use and Overdose, Accidental Death, Homicide, Suicide and Ill-
defined or Unknown. Within some of these categories, coroner or doctors can further classify death by
determine Underlying Cause of Death, for example, heart disease, unintentional drug overdose, sui-
cide, liver cancer, etc.
Categories of Death among People Experiencing Homeless in Alameda County, 2018-2021
Acute/chronic disease 99 119 186 153 557 44.2% 48.2%
Substance abuse and overdose 49 76 104 111 340 32.1% 29.4%
Unintentional injury 21 27 34 31 113 9.0% 9.8%
Homicide 16 15 28 22 81 6.4% 7.0%
Suicide 10 9 16 9 44 2.6% 3.8%
Unknown (R99) 0 0 0 20 20 5.8% 1.7%
In the following pages, we will more closely review deaths of people experiencing homelessness by
underlying cause of death:
Underlying Cause of Death: Drug Overdose
Drug overdose killed 106 homeless persons in 2021. It is the single leading cause of death among
people experiencing homelessness in Alameda County. Drug overdose is the single leading cause of
homeless death between 2018 and 2021 and homeless drug overdose deaths have tripled in that
time.
What is drug overdose? Drug overdose is one of the fast-
est-growing causes of death in the country and in Alameda
County. Drug overdose deaths are most frequently due to
opiates (mainly synthetic opiates such as fentanyl and fen-
tanyl compounds), heroin, and increasingly due to psy-
chostimulants such as methamphetamine. Many persons
are not aware of the presence of fentanyl-laced compound
drugs in their drug supply or the powerful potency of fen-
tanyl.
Most drug overdoses can be reversed and death prevented
by rapid action by nearby persons calling 911 and/or ad-
ministering naloxone (Narcan) before death occurs. Reach
out to the ACHCH program to access naloxone and training.
You can learn more about statewide analysis of overdose deaths in a 2022 California Overdose Crisis
Policy Brief from the State of California.
35
61
94 106
2018 2019 2020 2021
Homeless Drug Overdose Deaths
2018-2021
Alameda County Homeless Mortality Report 2021
27
Drug Overdose and Homeless Mortality
In 2021, 106 homeless Alameda County residents died of drug overdose. Homeless overdose deaths
continue to increase between 2018 and 2021, and since 2018, 297 persons experiencing homelessness
have died from drug overdose. Overdoses represented 30.6% of all 2021 homeless deaths. These
deaths represent an age-adjusted death rate of 888.1/100,000, a rate of drug overdose death 50.1
times that of the general population.
In 2021 in Alameda County as a whole, drug overdose claimed 358 lives. In 2021, people with recent
experience of homelessness (146) comprised 40.6% of all Alameda County drug overdose deaths.
Each homeless drug overdose death represents a premature death by an average of 45.0 years of life
lost, or a total of 4,680 years of life lost in 2021 in Alameda County.
The following analysis includes the 104 deaths attributed to accidental drug overdose in death certifi-
cate records AND two deaths classified as R99 Undetermined but containing direct references to pre-
sumed unintentional overdose.
Homeless Deaths Due to Overdose by Housing Status at Time of Death
Literally homeless at Recently homeless unknown housing
Location of Overdose Deaths
Overdose deaths almost always took place in an unattended setting; ten deaths were pronounced at a
hospital after transport from unknown locations.
City/Place of Overdose Death
Location of Homeless Drug Overdose Deaths
Oakland 71 68.3%
Hayward 9 8.7%
Berkeley 7 6.7%
San Leandro 4 3.8%
Emeryville 3 2.9%
Alameda 2 1.9%
Unknown 2 1.9%
Fremont 2 1.9%
Livermore 2 1.9%
Castro Valley 1 1.0%
Newark 1 1.0%
Alameda County Homeless Mortality Report 2021
28
This is a mapping of location of 80 of the 106 known homeless overdoses in Alameda County in 2021.
Not included in this map are 10 hospital deaths where the location of overdose was unknown, 12 over-
doses which took place at another person’s private residence and four accidental drug overdoses which
took place outside of Alameda County.
Drug Overdose Locations
Street/sidewalk 27 26.0%
Vehicle 16 15.4%
Encampment 16 15.4%
Other’s residence 12 11.5%
Outdoors 11 10.6%
Hospital (overdose location unknown) 10 9.6%
Motel 6 5.8%
Shelter 6 5.8%
Alameda County Homeless Mortality Report 2021
29
Homeless Drug Overdose Deaths by Various Demographics, 2021
Count Percentage
Region of county; last known residence
Mid-County 16 15.4%
Sex
Race/ethnicity
Age
Average age of death 47.4
Services noted in HMIS
* These are “other prescription and illicit opioids.” A text search revealed that almost all referred to fentanyl.
Note: A decedent may be represented in multiple lines due to multiple substance types involved in one overdose.
Drug Overdose Deaths by
Substance Type, 2018-2021:
0
10
20
30
40
50
60
2018 2019 2020 2021
Drug Overdose Deaths by
Substance Type, 2018-2021:
0
20
40
60
80
100
120
140
160
180
200
2018 2019 2020 2021
Alameda County Homeless Mortality Report 2021
30
In overdose deaths, many are due to a single substance or more commonly a combination of different
substances, such as heroin/fentanyl/methamphetamine. Due to a lack of detailed toxicology data, we
are not able to further break down some multi-substance use-related deaths. The following charts
show overdose deaths by substance types noted in death records.
Note: In these graphs, a decedent is represented in only one category.
Co-factors in Overdose Deaths
We were not able to view or analyze toxicology reports from the Coroner’s office. Examination of tox-
icology reports should enable a better ability to track fentanyl- and methamphetamine-involved fatal
overdoses.
In ten cases, we were unable to precisely map the exact locations where fatal overdoses occurred,
through death records we were not able to analyze if/when naloxone was administered, nor determine
if an overdose was alone or with other persons. All of these are important in analyzing overdose fatal-
ities.
Recommendations
• Expand and improve street- and field-based harm reduction-based substance use and treatment
services: Expand funding and support of field-based multidisciplinary teams to provide harm reduc-
tion services, reduce barriers to medication-assisted treatment, implement contingency manage-
ment programs, increase peer support and engagement. Expand community-based harm reduction
services include syringe distribution, naloxone and test strip distribution, and screening and referral
for SUD and physical/mental health needs. Include harm reduction supplies in county and city-
funded homeless outreach provider teams. Build on existing example of links between AHS Bridge
Clinic and harm reduction and homeless and housing providers.
• Expand naloxone distribution in street, shelter/housing and reentry settings: Overwhelming num-
bers of homeless drug overdose deaths take place outdoors, in vehicles or in public spaces. Develop
more approaches to get naloxone and OD response training to these locations. ACHCH Street
Health Teams currently distribute naloxone kits at street encampment sites; the ACHCH Shelter
Drug Overdose Deaths by Mutually
Exclusive Substance Type(s),
0
20
40
60
80
100
120
2018 2019 2020 2021
Drug Overdose Deaths by Mutually
Exclusive Substance Type(s),
0
50
100
150
200
250
300
350
400
2018 2019 2020 2021
Alameda County Homeless Mortality Report 2021
31
Health program is installing naloxone
distribution boxes at homeless shel-
ters and services centers and provid-
ing overdose training to all staff and
outreach providers. Ensure that peo-
ple experiencing homelessness are
provided with naloxone, education,
and referrals before release from jail.
Better track naloxone use and effec-
tiveness through consolidating both
distribution and tracking of reversals.
• Expand and improve SUD services for
people experiencing homelessness:
Expand capability to provide low-bar-
rier accessible interim or transitional
housing to all people experiencing
homelessness. Integrate SUD services
into homeless shelter and outreach
projects, expand and enhance home-
less services providers training on
SUD interventions for both perma-
nent supportive housing, shelter/interim
housing, and outreach programs. Expand
low barrier outpatient services to increase access to Medication Assisted Treatment in clinics and
sites (example: AHS Bridge Clinic), with peer-supported support, behavioral health, contingency
management programs, with coordination between SUD services and housing providers. Increase
access to low-barrier inpatient SUD detox and recovery services with peer-support and behavioral
health focus; increase numbers of inpatient SUD beds, reduce wait time for inpatient beds and
reduce barriers for people interested in accessing inpatient recovery and detox services.
• Community-based drug checking: Initiate low-barrier, accessible testing of actual samples of the
drugs used by Alameda County residents who use drugs through use of FT/infrared spectrography
directly provided by trusted harm reduction practitioners at street-based locations. This is a way
for people who use drugs to directly know what is in the substances they are using and change
behaviors accordingly, and for countywide surveillance and response to contaminants entering the
supply of drugs used.
• Safer consumption sites: Safer consumption sites are supportive locations providing observation
and treatment of people who inject drugs, preventing fatal overdose, effectively connecting high-
risk individuals with treatment, reduce stigma and isolation among injection drug users, and pro-
vide access to harm reduction and lifesaving resources. Boston Health Care for the Homeless has
an outstanding example of safe injection sites for people experiencing homelessness.
• Coroner toxicology data: We need timely data from the Alameda County Coroner’s Office regarding
toxicology testing results for drug overdose deaths. Rapid review and dissemination of Coroner’s
data is one of the main ways that localities can be informed about rises/surges in xylazine and other
dangerous contaminants in drug supply.
Alameda County Homeless Mortality Report 2021
32
Category of Death: Acute and Chronic Medical Conditions
In Alameda County between 2018 and 2020, 403 deaths (or 50%) of people experiencing homelessness
were due to acute or chronic medical conditions, also known as natural causes. Epidemiologists cate-
gorize these deaths into categories by the Underlying Cause of Death diagnosis code (ICD-10 code)
determined by the coroner, pathologist or treating physician. These are the following categories of
underlying cause of death for people experiencing homelessness who died between 2018 and 2021.
Homeless Deaths Due to Acute/Chronic Disease, 2018-2021
Percentage Percentage
Heart disease 40 34 42 54 170 36.2% 31.8%
All other diseases 17 24 43 35 119 23.5% 22.2%
Cancer (malignant neoplasms) 15 18 16 16 65 10.7% 12.1%
Chronic liver disease/cirrhosis 11 13 23 8 55 5.4% 10.3%
Cerebrovascular disease 4 7 13 4 28 2.7% 5.2%
CLRD (chronic lower respiratory disease) 2 9 10 7 28 4.7% 5.2%
Other communicable diseases 1 4 11 4 20 2.7% 3.7%
Diabetes, metabolic 3 1 7 4 15 2.7% 2.8%
Hypertensive renal disease/essential
hypertension 1 3 3 6 13 4.0% 2.4%
Total 95 114 177 153 535 100.0% 100.0%
Homeless Deaths Due to Acute/Chronic Disease by Housing Status at Time of Death
Literally homeless at Recently homeless unknown housing
Total 535 312 628
Homeless Deaths Due to Acute/Chronic Disease by
Various Demographics, 2021
Count Percentage
Total 153
Region of county
Oakland/Emeryville 83 54.2%
Alameda County Homeless Mortality Report 2021
33
Unattended deaths
Sex
Race/ethnicity
Age
Average age at death 57.6
Services noted in HMIS
Category of Death: Accidental Death
Accidental Deaths and Homeless Mortality
In Alameda County in 2021, 31 persons experiencing homelessness died by traumatic accidental death.
This number does not include accidental drug or alcohol overdose. Included in the category of acci-
dental deaths are the following causes of death.
Homeless Deaths Due to Accidental Causes
Pedestrian or bicyclist hit by vehicle 9 11 13 9 42 29.0% 40.2%
Struck by train 4 4 4 4 16 12.9% 14.6%
Passenger or driver of vehicle in crash 1 3 9 3 16 9.7% 15.9%
Fall 1 3 2 7 13 22.6% 7.3%
Drowning 2 3 0 1 6 3.2% 6.1%
Fire or smoke inhalation 1 2 1 1 5 3.2% 4.9%
Ill-defined or unknown cause of injury 1 2 1 5 9 16.1% 4.9%
Hypothermia 2 1 0 1 4 3.2% 3.7%
Carbon monoxide poisoning in tent/car 0 0 2 0 2 0.0% 2.4%
Total 21 29 32 31 113 100.0% 100.0%
In 2021, 9.0% of all homeless deaths were due to accidental death. By far, pedestrian deaths are the
most frequent (non-drug overdose) accidental cause of death among people experiencing homeless-
ness. In 2021, Alameda County people experiencing homelessness had a pedestrian death rate 27.6
times that of the general population, 110 times the rate of being struck by a train, and 11.8 times the
rate of dying by other unintentional injuries.
Alameda County Homeless Mortality Report 2021
34
Location of Accidental Deaths
Most accidental deaths do not take place in hospitals or facilities and as such are unattended except
by emergency responders. Here are the locations in which people experiencing homelessness died by
homicide as reported in CCDF.
Homeless Deaths Due to Accidental Causes Setting/Location of Injury
Street/sidewalk 35 42.7%
Railroad 15 18.3%
Traffic accident 11 13.4%
Outdoors 9 11.0%
Vehicle 5 6.1%
Other’s residence 2 2.4%
Encampment 2 2.4%
Jail 1 1.2%
Unknown 1 1.2%
Shelter 1 1.2%
Demographics
Homeless Deaths Due to Accidental Injuries by Housing Status at Time of Death
Literally homeless at homeless but unknown housing
Total 113 9 23
Homeless Deaths Due to Accidental Injuries by Various Demographics, 2021
Count Percentage
Total 31
Region of county
Sex
Race/ethnicity
Alameda County Homeless Mortality Report 2021
35
Age
Average age at death 52.0
Services noted in HMIS
Underlying Cause of Death: Homicide
Homicide and Homeless Mortality
In Alameda County in 2021, 22 persons experiencing homelessness died by homicide. This represents
6.4% of all homeless deaths, and an age-adjusted death rate of 198.3/100,000, or 22.9 times that of
the general population.
The average age of homicide death for homeless persons is 41 years, as compared to the average for
the general population of 35 years.
Homicide deaths were most frequently due to gunshot (73%), stabbing, strangling, bludgeoning, and
fire.
Location of Homicide Deaths
Here are the locations in which people experiencing homelessness died by homicide as reported in
CCDF.
Homeless Deaths Due to Homicides Setting/Location of Injury
Street/sidewalk 19 86.4%
Outdoors 1 4.5%
Encampment 1 4.5%
Other’s residence 1 4.5%
Demographics
Homeless Deaths Due to Homicides by Housing Status at Time of Death
Literally homeless at homeless but unknown housing
Total 81 8 27
Alameda County Homeless Mortality Report 2021
36
Homeless Homicide Deaths by Various Demographics, 2021
Region of county
Sex
Race/ethnicity
Unattended Death
Age
Average age at death 43.2
Services noted in HMIS
Underlying Cause of Death: Suicide
Suicide and Homeless Mortality
In Alameda County in 2021, 9 persons experiencing homelessness died by suicide. This represents 2.6%
of all homeless deaths, and an age-adjusted death rate of 85.8/100,000, or 10.0 times that of the gen-
eral population.
The most common method of suicide was hanging/suffocation, followed by jumping in front of traffic
or train, gunshot, drug, and others.
Homeless Deaths Due to Suicide Setting/Location of Injury
Struck by Train 3 33.3%
Jail 2 22.2%
Other’s Residence 2 22.2%
Motel 1 11.1%
Vehicle 1 11.1%
Alameda County Homeless Mortality Report 2021
37
Demographics
Homeless Deaths Due to Suicides by Housing Status at Time of Death
Literally homeless at homeless but unknown housing
Total 44 9 8
Homeless Suicide Deaths by Various Demographics, 2021
Region of county
Sex
Race/ethnicity
Age
Average age at death 34.2
Services noted in HMIS
Underlying Cause of Death: R99 – Ill-Defined or Unknown Cause of Death
R99 In 2021, 20 homeless deaths were classified as ill-defined or unknown causes of death. 9 of these
cases were still under investigation at time of analysis. This includes four persons found decomposed
or skeletal for whom homicide was not suspected and a natural cause of death could not be deter-
mined. These also include cases of probable cause of death including two presumed drug overdoses,
one HIV-related pneumonia, alcoholism, deaths being investigated as whether accidental or inten-
tional. 16 of the 20 R99 deaths were persons who passed away outdoors in an unattended setting.
Alameda County Homeless Mortality Report 2021
38
Mortality Rates, Premature Mortality Rates, and Comparisons to the Gen-
eral Population
With alignment between death records data of both people experiencing homelessness and the gen-
eral population of Alameda County, we are able to compare general demographic data between
housed and unhoused populations, and compare mortality rates between housed and unhoused pop-
ulations, and compare premature mortality rates (YLL) comparing homeless mortality numbers and
demographics with the Alameda County general population recorded deaths in 2021.
Deaths by Ethnicity Comparison between People Experiencing Homelessness
and Alameda County General Population, 2021
Race/Ethnicity
Count Percentage
Total 346 11,226 100.0% 100.0%
Deaths by Gender Comparison between People Experiencing Homelessness
and Alameda County General Population, 2021
Homeless General
Population Homeless General
Population
Male 263 5,911 76.0% 52.7%
Female 83 5315 24.0% 47.3%
Total
Mean Age of Death Comparison between People Experiencing Homelessness
and Alameda County General Population 2021
Homeless General
Population
All Cause 51.7 72.7
Homicide 43.2 33.9
Suicide 34.2 47.2
Accidental injury 52.0 56.3
Acute/chronic disease 58.0 75.6
Substance abuse and overdose 48.0 46.8
Unknown/Undermined 41.1 37.6
Alameda County Homeless Mortality Report 2021
39
Mortality Rates for the Alameda County General Population Compared to Persons Experiencing
Homelessness
The overall age-adjusted mortality rate for people experiencing homelessness is 3,336.2 deaths per
100,000 persons. This is compared to the age-adjusted mortality rate for the Alameda County general
population of 572.1 per 100,000 persons. The 2021 Mortality Rate Ratio (MRR) for persons experienc-
ing homelessness is 5.8 meaning that in 2021, people experiencing homelessness in Alameda County
died at a rate 5.8 times that of the general population.
The mortality rate for persons experiencing homelessness is based on a denominator of 9,490 people
on average experiencing homelessness in Alameda County per day in 2021. This number was arrived
at through linear regression of three Point-In-Time Counts (2017, 2019, 2022) to estimate the number
of people experiencing homelessness on 7/1/2021.
A mortality rate ratio (MRR) of 1.0 indicates equal rates in the two groups. An MRR greater than 1.0
indicates an increased risk for the group in the numerator, and an MMR less than 1.0 indicates a de-
creased risk for the group in the numerator. For example, in 2018-2020, people experiencing home-
lessness died of unintentional drug overdoses at a rate 50.1 times that of the general Alameda County
population.
Underlying Cause of Death
Deaths 2021
Age-Adjusted
Mortality Rate Mortality
Rate Ra-
Homeless
General
Population Homeless
General
Population
5.8
Unintentional or undetermined intent overdose 104 316 888.1 17.7 50.1
Heart disease 54 2,093 577.7 105.2 5.5
All other diseases 35 1,560 321.4 79.1 4.1
Homicide 22 142 198.3 8.6 22.9
Cancer (malignant neoplasms) 16 2,293 178.5 115.0 1.6
All other injuries 17 268 167.4 14.2 11.8
Unknown (R99) 19 64 160.1 3.5 45.4
COVID-19 9 805 108.5 41.0 2.6
Chronic liver disease and cirrhosis 8 205 98.0 10.6 9.2
CLRD 7 359 95.5 17.8 5.4
Sequelae of drug and alcohol use & dependence 7 59 90.3 3.2 28.5
9 56 84.1 3.0 27.6
6 272 76.2 13.6 5.6
4 5 30.0 0.3 110.3
Alameda County Homeless Mortality Report 2021
40
0 56 0.0 3.7 NA
Premature Mortality (Years of Life Lost)
Years of life lost (YLL) is a way of measuring the impact of deaths occurring prematurely. The YLL rate
ranks the causes of death by the those causes leading to more cumulative premature years lost—dy-
ing at a younger age contributes more to the YLL than dying at an older age. The age of death matters
greatly together with the number (or rate) of deaths. The YLL per death shows the average number of
years of life which potentially could have remained for each person’s death by that cause. The rates
are useful for comparing populations such as those experiencing homelessness vs. the general popu-
lation; adjusting for age accounts for different age structures.1
Underlying Cause of Death
Homeless Population General Population
YLL
Rate
Deaths
With
Known
YLL
per
justed YLL
Rate per
100,000 per
Deaths
With
Known
YLL
per
justed YLL
Rate per
100,000 per
Total 339 40.8 128,118.7 11,226 21.3 12,716.0 10.1
104 45.0 40,344.2 316 46.5 849.7 47.5
9 43.4 3,538.5 56 40.4 127.5 27.7
7 36.4 2,882.4 59 33.5 111.0 26.0
6 30.1 2,134.3 272 17.3 237.5 9.0
In reviewing the above “Total” line, we see that among the 339 homeless deaths with a known age the
average death resulted in 40.8 years of potential life prematurely lost. This means an age-adjusted YLL
rate of 128,118/100,000 for people experiencing homelessness, meaning that the average homeless
death means 10 times higher loss of potential life years than the general population.
1. This version of years of life lost (YLL) is based on the Global Burden of Disease’s latest method. This method uses a 2050 frontier life expectancy—a life expectancy that is projected for the healthiest group in the world in 2050—for each year of age. In effect, there is no single cutoff for life expectancy, instead using a more typical life table approach where there is a life expectancy for each year of age. For instance, at birth the 2050 frontier life expectancy is 91.94 years, compared to 65 years when the 2050 frontier life expectancy is 27.86.
Alameda County Homeless Mortality Report 2021
41
Reviewing YLL by underlying cause of death, we see people experiencing homelessness die at much
earlier age (YLL per death) and at much higher rates than the general population (age-adjusted YLL
rate) by all causes of death. Some details include:
• Heart disease: 51 homeless people who died of heart disease died an average of 34.5 years earlier
than expected. This compares to the general population where the average heart disease death
meant a potential loss of 17.6 years of life.
• Drug overdose: The average homeless overdose death meant a loss of 45.0 potential years of life
per overdose. Within the general population, each overdose death meant a similar 46.5 years lost;
however, the higher mortality rate of drug overdose deaths among people experiencing homeless-
ness means that the YLL ratio is, incredibly, 47.5 times the rate for people experiencing homeless-
ness than the general population.
• Homicide: The average homeless death by homicide represents a loss of 49.1 potential years of life.
In the general population, homicide victims, generally younger than their unhoused counterparts,
lost an average of 57.0 potential years of life. But again, the high mortality rate of homicide among
people experiencing homelessness means they have a YLL ratio 19.6 times that of the general pop-
ulation.
• Acute and chronic diseases: The combination of a much earlier average age of death and much
higher mortality rates for people experiencing homelessness meant that the YLL rate for people
experiencing homelessness is in all cases much higher than that for the general population.
Services Utilization and Homeless Mortality
A key element of analyzing and learning from homeless mortality is to review the utilization of home-
less, health care and other services among people experiencing homelessness who have died. Services
used by people experiencing homelessness can include the following.
• Primary care clinics and providers
• Hospitalization and emergency department
• Housing services (emergency shelter and housing services)
• Outreach services
• Behavioral health services (mental health and substance use disorder)
• Harm reduction services
• Criminal justice system involvement
• Social services utilization
• Veteran status and services utilization
• Foster care system utilization
In this report, were not able to fully “connect the pieces” between people experiencing homelessness
and the services they utilized – or didn’t utilize – in the times leading to their deaths. This type of data
analysis is a strong goal for future Alameda County homeless mortality efforts. A good example of ser-
vices utilization reporting is carried out by San Francisco: https://nhchc.org/wp-content/up-
loads/2020/12/San-Francisco-2019-Homeless-Mortality-Health-Commission.pdf
Homeless Services Utilization: Homeless Management Information System (HMIS)
In this report, we were able to evaluate how many of the people experiencing homelessness who died
in 2021 utilized Alameda County Homeless Management Information System (HMIS) which is the sys-
tem used to track users of HUD-funded homeless shelter and services in Alameda County. We also
Alameda County Homeless Mortality Report 2021
42
matched decedents to the Alameda County Health Care for the Homeless (ACHCH) program data of
people who had received health care at ACHCH mobile or clinic sites.
Through this data matching, we found that, of the 346 persons deemed to be literally homeless at time
of death in 2021:
• 57.8% had a history of services utilization with the HMIS system;
• 63.6% were locatable within the Alameda County Social Health Information Exchange (SHIE)
• 50.2% had had contact with the Alameda County Health Care for the Homeless health center pro-
gram.
Of the 97 persons without history of HMIS, SHIE or ACHCH contact, 49 were deaths reported by the
Coroner’s Office as “transient”.
We hope in future reports to evaluate much more closely utilization of homeless services and the above
services to gain a better understanding of the relationships between homeless services and mortality.
Homelessness System Implications and Next Steps
This 2021 report is a data report for review and analysis, which will be useful in informing policy and
practice across the homelessness system of care, including health care, government, and community
partners.
Next steps for our County and partners include:
• Regular homeless mortality reporting. HCSA will regularly update and improve this report, ideally
on an annual basis.
• Establishment of the Alameda County Homeless Mortality Review Team. In 2023, HCSA’s home-
lessness programs will bring together leads from varied County and city departments and commu-
nity organizations to meet regularly to review and analyze homeless mortality data, trends, cases,
and best practices, and provide policy and practical recommendations and feedback to homeless
health care and services providers. To learn more about this or apply to be part of the AC HMRT,
go to www.achch.org/alameda-county-homeless-mortality.html
• Continuous data quality improvement
o HCSA’s team will continue to partner with the Alameda County Coroner’s Office to access and
integrate more robust data, especially regarding overdose data and associated toxicology re-
porting.
o HCSA’s team will continue to leverage service utilization data from touchpoints across the
homelessness system of care, including housing, health clinics, hospitals, emergency room, be-
havioral health, social services, outreach, and criminal justice.
• Provider-based mortality review is the process by which health and services providers review the
circumstances of deaths of individuals that they have treated or served, to explore root causes and
identify interventions to prevent future deaths. When carried out systematically by providers such
as health clinics, outreach providers and homeless shelters, mortality review can improve care and
future health outcomes among people experiencing homelessness. A key element of provider mor-
tality review also includes responding to the trauma and effects of mortality upon services
Alameda County Homeless Mortality Report 2021
43
providers themselves. For more information about clinic or site-based mortality review, please go
to: https://nhchc.org/wp-content/uploads/2020/12/Section-4-Toolkit.pdf
If you are interested in providing input or guidance to the Alameda County Health Care for the Home-
less program around the issues of homeless mortality, please reach out to achch@acgov.org.
The Alameda County Health Care for the Homeless program also maintains a webpage with homeless
mortality information and a form for submitting the names and some data around people known by
community providers to have died in homelessness. These community reports help us carry out a more
accurate and effective homeless mortality reporting.
https://www.achch.org/alameda-county-homeless-mortality.html
Appendix
Other California/Regional Homeless Mortality Reports
Los Angeles Analysis of medical
examiner reported 2022; 56% increase Advisory Group to make recommendations.
port 1,506 since 2002 End Homelessness with help from coroner’s
Please see https://nhchc.org/homeless-mortality/ to access national homeless mortality information,
toolkits, resources, and join the national Homeless Mortality Working Group.