Examining contextual influences on the service needs of homeless and unstably housed domestic violence survivors

Change in address in electronic health records as an early marker of homelessness

INTRODUCTION

Housing stability is a key health determinant and there is a need for early screening for instability with existing electronic health record (EHR) data to improve health outcomes. We aim to establish recorded address changes as a screening variable for housing instability and homelessness and to attempt to define the threshold of high churn.

METHODS

Our study is a single-center cross-sectional study of EHR data (2018-2024) conducted at a US academic center with eleven sites across Chicago. We include patients 18 years or older with at least three hospital encounters over three different years. We define address churn as the number of address changes recorded in the EHR corrected to three-year intervals. We compare demographic and clinical characteristics of individuals with varying address churn with the student T-test to look at distribution of address churn for patients with and without record of homelessness, ANOVA to evaluate the distribution of ages for different levels of churn, and the chi-square test to evaluate for association between churn and clinical diagnoses. We perform multivariable logistic regression to measure the association between people with a record of homelessness and address changes.

RESULTS

The study includes 1,068,311 patients with 756,222 having zero address changes, 156,911 having one address change, 137,491 with two address changes, 9,558 with three address changes, and 8,129 with four or more address changes. People with no record of homelessness in the EHR have mean address changes of 0.6 (SD 0.7) whereas people with record of homelessness have mean address changes of 1.8 (SD 1.3). Diagnostic profiles of the varying address change groups show increased prevalence of psychiatric diagnoses (65.2% in the 4 or more-address change group) compared to lower address change (27.7% in the 0-address change group). Address churn is significantly associated with homelessness with an odds ratio (OR) of 1.44 (95% CI =  [1.42-1.47], P < 0.001).

CONCLUSION

Our results support a role for residential address churn in screening for housing instability in healthcare systems and reinforce the association between psychiatric disorders and housing instability. Our findings can help public health policy makers in targeting vulnerable populations at risk of homelessness with multiple health comorbidities for housing interventions.

Can This Provider Be Trusted? A Review of the Role of Trustworthiness in the Provision of Community-Based Services for Intimate Partner Violence Survivors

While there is a growing literature on intimate partner violence (IPV) survivors and service providers, it is limited by its largely atheoretical and descriptive nature, and its emphasis on individual-level survivors' help-seeking. We seek to broaden our understanding by shifting the focus onto organizations and service systems and introducing the concept of these providers' trustworthiness toward survivors. Provider trustworthiness in delivering services includes benevolence (locally available and caring), fairness (accessible to all and non-discriminatory), and competence (acceptable and effective in meeting survivors' needs). Guided by this conceptualization, we conducted an integrative review drawing on four databases: PsycINFO, PubMed, Web of Science, and Westlaw. We identified studies for inclusion that were published between January 2005 and March 2022, and we examined the trustworthiness of community-based providers serving adult IPV survivors in the United States, including domestic violence services, health and mental health care, the legal system, and economic support services (N = 114). Major findings include (1) many survivors live in communities with no shelter beds, mental health care, or affordable housing; (2) many services are inaccessible because they lack, for example, bilingual staff, sliding fees, or telehealth options; (3) too many providers are harmful or discriminatory toward survivors, especially those who are, for example, sexual or gender minorities, immigrants or non-English-speaking, poor, or Native, Black, or Latinx; (4) many providers appear to be incompetent, lack evidence-based training, and are ineffective in meeting survivors' needs. We call on researchers, advocates, and providers to examine provider trustworthiness, and we offer an introduction to measuring it.

Actionable research for understanding and addressing homelessness

Homelessness results from an interaction of structural determinants and individual vulnerabilities, creating various pathways into homelessness and having multilevel impacts. Understanding and addressing homelessness requires research that not only takes an ecological perspective but also can be translated into action. Despite research demonstrating differing needs and experience among various subpopulations, particularly marginalized groups, homeless service systems often take a one-size-fits-all approach. Additionally, homeless service systems' prioritization of the most vulnerable and chronically homeless for permanent housing programs results in a service system that operates in a state of triage, with minimal attention to prevention efforts. This special issue highlights actionable research focused on preventing homelessness and addressing disparities among marginalized groups. Included articles target homelessness at multiple levels using a combination of qualitative, quantitative, and mixed-methods approaches. Embedded in community psychology values, this study focuses on prevention, leverages participatory methods, relies on diverse lived experiences, and explores community-based solutions.