Prevalence of Homelessness in the Emergency Department Setting

Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED

Importance

Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness.

Objective

To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization.

Design, Setting, and Participants

This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023.

Main Outcomes and Measures

The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization.

Results

Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results.

Conclusions and Relevance

In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.

Feasibility of group telerehabilitation for individuals with chronic acquired brain injury: integrating clinical care and research

BACKGROUND

Acquired brain injury (ABI) is a leading cause of lifelong disability, but access to treatment in the chronic stages has significant barriers. Group-based, remotely delivered neurorehabilitation reduces costs, travel barriers, and infection risk; however, its feasibility for patients with ABI is not well-established.

OBJECTIVES

To investigate the feasibility of remotely group-based cognitive and mood therapies for persons with chronic ABI.

METHODS

Three hundred and eighty-eight adults with chronic ABI participated in group tele-neurorehabilitation modules comprising Cognitive Behavioral Therapy, Goal Management Training®, Relaxation and Mindfulness Skills Training, and/or a novel Concussion Education & Symptom Management program. Assessments comprised quantitative metrics, surveys, as well as qualitative semi-structured interviews in a subset of participants.

RESULTS

High retention, adherence, and satisfaction were observed. Facilitators of treatment included accessibility, cost-effectiveness, and convenience. Adoption of technology was high, but other people's technological interruptions were a barrier. Self-reported benefits specific to group-based format included improved mood, stress management, coping, interpersonal relationships, cognitive functioning, and present-mindedness.

CONCLUSIONS

The present study examined chronic ABI patients' perceptions of telerehabilitation. Patients found remotely delivered, group-based mood, and cognitive interventions feasible with easy technology adoption. Group format was considered a benefit. Recommendations are provided to inform design of remotely delivered ABI programs.

Prevalence of homelessness among hospitalized patients: A point-in-time survey

Although homelessness is associated with increased acute healthcare utilization and poorer health outcomes, the prevalence of homelessness and housing insecurity in hospitalized patients is poorly characterized. We conducted an in-person survey to determine the prevalence of housing insecurity and homelessness among hospitalized patients at two hospitals in metropolitan Denver in conjunction with the Housing and Urban Development point-in-time count on January 24, 2022. Of the 271 surveyed patients, 79 (29.2%) reported experiencing either housing insecurity (17.3%) or homelessness (11.8%). Of those experiencing housing insecurity or homelessness, 69.6% reported chronic health conditions, 55.7% reported multiple hospitalizations in the preceding year, 38% reported mental health concerns and 39.2% reported substance use. The prevalence of homelessness among a hospitalized patient population was over 20-fold higher than community prevalence estimates. Housing insecurity also impacted a substantial proportion of hospitalized patients and was associated with high rates of co-morbid conditions.

Emergency Department Use Among Recently Homeless Adults in a Nationally Representative Sample

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness. Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1-4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use. Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio [OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and health variables, homelessness was no longer significantly associated with moderate or high ED use in the prior year. Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

Effects of California’s New Patient Homelessness Screening and Discharge Care Law in an Emergency Department

Introduction California State Bill 1152 (SB1152) mandated all non-state-operated hospitals meet specific criteria when discharging patients identified as experiencing homelessness. Little is known about SB1152's effect on hospitals or compliance statewide. We studied the implementation of SB1152 in our emergency department (ED). Methods We analyzed our suburban academic ED's institutional electronic medical record for one year before (July 1, 2018-June 20, 2019) and one year after (July 1, 2019-June 30, 2020) implementation of SB1152. We identified individuals by lack of address during registration, International Classification of Diseases, Tenth Revision (ICD-10) code of homelessness, and/or the presence of an SB1152 discharge checklist. Demographics, clinical information, and repeat visit data were collected. Results ED volumes were constant during the pre- and post-SB1152 periods (approximately 75,000 annually); however, ED visits by people experiencing homelessness more than doubled (630 (0.8%) to 1530 (2.1%) in the pre- and post-implementation periods. Age and sex distributions were similar with approximately 80% of patients aged 31-65 years and less than 1% under 18. Visits by females comprised less than 30% of the population. Visits by people of the White race decreased from 50% to 40% pre- and post-SB1152. Visits by people of the Black, Asian, and Hispanic races experiencing homelessness increased by 18% to 25%, 1% to 4%, and 19% to 21%, respectively. Acuity was unchanged with 50% of visits classified as "urgent." Discharges increased from 73% to 81% and admissions halved from 18% to 9%. Visits by patients with only one ED visit decreased (28% to 22%); those with four or more visits increased (46% to 56%). The most common primary diagnoses pre- and post-SB1162 were alcohol use (6.8% and 9.3%, respectively), chest pain (3.3% and 4.5%, respectively), convulsions (3.0%, and 2.46%, respectively), and limb pain (2.3% and 2.3%, respectively). The primary diagnosis of suicidal ideation doubled from the pre- to post-implementation periods (1.3% to 2.2%, respectively). Checklists were completed for 92% of identified patients discharged from the ED. Conclusion Implementation of SB1152 in our ED resulted in identifying an increased number of persons experiencing homelessness. We identified opportunities for further improvement since pediatric patients were missed. Further analysis is warranted, especially with the coronavirus disease 2019 (COVID-19) pandemic, which has significantly affected healthcare-seeking behavior in EDs.

Association of Social Needs and Housing Status Among Urban Emergency Department Patients

Introduction

People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness.

Methods

We surveyed patients in an urban, safety-net ED from June–August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability.

Results

Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29–57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics.

Conclusion

Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting. Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health. Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting? Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

Homelessness and the use of Emergency Department as a source of healthcare: a systematic review

BACKGROUND

Persons experiencing homelessness (PEH) often use hospital Emergency Department (ED) as the only source of healthcare. The aim of this study was to undertake a systematic review to identify the prevalence, clinical reasons and outcomes in relation to ED visits by PEH.

METHODS

A protocol-led (CRD42020189263) systematic review was conducted using search of MEDLINE, EMBASE, CINAHL and Google Scholar databases. Studies that reported either the prevalence of homelessness in the ED or clinical reasons for presentation to ED by PEH and published in English language were included. Definitions of homelessness used by study authors were accepted.

RESULTS

From the screening of 1349 unique titles, a total of 36 studies were included. Wide variations in the prevalence and key cause of presentations were identified across the studies often linked to differences in country, study setting, disease classification and data collection methods. The proportion of ED visits contributed by PEH ranged from 0.41 to 19.6%. PEH made an average of 0.72 visits to 5.8 visits per person per year in the ED [rate ratio compared to non-homeless 1.63 to 18.75]. Up to a third and quarter of the visits were contributed by alcohol-related diagnoses and substance poisoning respectively. The percentage of PEH who died in the ED ranged from 0.1 to 0.5%.

CONCLUSIONS

Drug-, alcohol- and injury-related presentations dominate the ED visits by PEH. Wide variations in the data were observed in regard to attendance and treatment outcomes. There is a need for prevention actions in the community, integrated discharge and referral pathways between health, housing and social care to minimise frequent usage and improve attendance outcomes.

Emergency Department Use by Women Experiencing Homelessness in Los Angeles, California, USA

Background:

This article reports on the use of hospital Emergency Departments (EDs) in women experiencing homelessness in Los Angeles, California. Women 18 years of age or older were recruited from homeless day centers in Los Angeles to participate in this study.

Materials and Methods:

A self-report questionnaire on health status, demographics, and emergency service use was completed by study participants.

Results:

In this study of women experiencing homelessness, 64% utilized the ED within the past year. The mean number of ED use was 3.63 (range 0–20) visits in the past year. Higher frequency visits were significantly associated with several mental health conditions (p = 0.016), physical disability (p = 0.001), and traumatic brain injury (p = 0.013).

Conclusions:

The physical and psychological impacts of the homelessness experience can be enormous, affecting the homeless individually and collectively. Study findings may help to understand how to improve services that support and meet the needs of women experiencing homelessness such as patient and family-centered care and trauma-informed care in the ED.

Prevalence of Housing Insecurity in Survivors of Traumatic Injury

BACKGROUND

Almost 20% of the US population are housing insecure (HI) due to inadequate living conditions, imbalanced costs to income, nonsustainable shelter, or overcrowding. Housing insecure and physical trauma share similar risk factors, but their direct association is not well elucidated. The objective of our study was to determine the prevalence of HI in survivors of traumatic injury.

METHODS

We conducted a prospective cohort study at an urban, level 1 trauma center. A survey on social determinants of health was administered to adult patients, and demographic, injury specifics, and clinical outcomes data were collected. HI was defined by affirmative answers to questions related to history of homelessness or concern about sustainable shelter. The cohort was stratified by HI; groups were compared using the Mann-Whitney U and Fisher exact tests, as appropriate.

RESULTS

Of 116 study participants, four were excluded due to missing data. Of the 112, 42 (37.8%) reported HI and most were black (69%) males (73.8%). There were no demographic differences between groups. Conversely, HI patients had a higher rate of penetrating traumatic injury (34.1% vs 14.5%, P-value = .03) and were significantly less educated compared to secure participants (P-value = .03) [no degree (26.2% vs 10.3%), high school degrees (21.4% vs 41.2%)] with concomitant illicit drug use (63.4% vs 27.9%, P < .001), and history of addiction (52.4% vs 7.2%, P < .001).

CONCLUSION

HI far exceeds national averages in our cohort. Although difficult to ascertain a cause-effect relationship, HI may be a modifiable risk factor for trauma that negatively influences outcomes.

A Study on the Efficacy of a Naloxone Training Program

Introduction: The use of naloxone to reverse a potentially fatal opioid overdose is a harm reduction strategy that reduces mortality and increases the potential for referral to substance use treatment for affected individuals. In the setting of outreach performed by a street medicine team, we aimed to determine the effectiveness of an educational intervention involving distribution of naloxone accompanied by a brief instructive session about opioids, opioid overdose, and medication administration.

Methods: Our street medicine outreach team distributed 200 naloxone kits to clinicians and volunteers involved in caring for patients on ‘street rounds,’ as well as in shelters, soup kitchens, and street medicine clinic settings. Those receiving a naloxone kit engaged in a peer-reviewed presentation on how to safely use the medication to reverse a potentially fatal opioid overdose. The study team developed and administered a pre- and post-survey of 10 multiple choice questions on material covered in the educational training. The pre- and post-survey scores were compared to assess the effectiveness of implementing this training. Results were stratified by participant gender and age group.

Results: Out of the 200 participants, six were excluded from the analysis due to completely missing data from one or both surveys. The mean age of participants was 40.2±12.5 years; 120 (65.6%) were female, 62 (33.9%) were male, and 1 (0.6%) identified as nonbinary. Every survey question had an increase in correct responses from pre-survey to post-survey (identified by an increase in the percentage of correct responses). The mean survey total score increased from 5.5±1.6 to 7.5±1.3. Within the sample of 194, the mean difference in scores from pre-survey to post-survey was 2.02 points (95% CI [1.77, 2.26]), p<0.0001. Males had a mean increase in the total score from 5.6±1.8 to 7.4±1.1. Females had a mean increase in the total score from 5.5±1.5 to 7.5±1.3. The difference in total scores in males was 1.89 points (95% CI [1.42, 2.35]), p<0.0001, and in females was 2.02 points (95% CI [1.71, 2.32]), p<0.0001. Post-test scores improved in all age groups.

Conclusion: The educational training on opioids, opioid overdose, and the use of naloxone was an effective adjunct to naloxone kit distribution to volunteers and clinicians caring for people experiencing homelessness.

Using community-based participatory research methods to inform care for patients experiencing homelessness: An opportunity for resident education on health care disparities

People experiencing homelessness (PEH) suffer higher burdens of chronic illnesses, have higher rates of emergency medicine (ED) use and hospitalization, and ultimately are at increased risk for premature death compared to housed counterparts. Structural racism contributes to a disproportionate burden of homelessness among people of color. PEH experience not only significant medical concerns but also complex social needs that need to be addressed concurrently for effective healing, issues that have been magnified by the COVID-19 pandemic. As health disparities and structural racism intersect among PEH, it is critically important to develop PEH-centered interventions to improve care and health outcomes as part of an effort to dismantle racism. One opportunity to address these disparities in care for PEH is through training ED physicians on methods for identifying and intervening on the unique needs of vulnerable patient groups. The Accreditation Council for Graduate Medical Education has outlined health quality pathways in the clinical learning environment to address health disparities. Community-based participatory research (CBPR) is particularly well suited for this scenario as it allows experiential learning for trainees to work with and understand a diverse group of stakeholders, to deepen their knowledge of local health disparities, and to lead research and measure outcomes of interventions to tackle health disparities. In this paper, we highlight the utility of CBPR in fostering experiential learning for EM residents on tackling health disparities and the importance of community collaboration in trainee-led interventions for comprehensive ED care.

Identifying homeless population needs in the Emergency Department using Community-Based Participatory Research

Background

Annually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care.

Methods

A needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted.

Results

Twenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders.

Conclusion

CBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.

Disparities in communication among the inpatient homeless population at a safety-net hospital

OBJECTIVE

To determine whether the homeless population experiences disparities in care and communication during inpatient hospitalizations in a safety-net hospital.

METHODS

We administered a modified Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to 112 age-sex- and education matched homeless and non-homeless adults at a university-affiliated-safety-net hospital from December 2017 through March 2018 and performed a retrospective review of medical records. Linear regression models were used to assess differences in responses to survey subscales, length of stay and other measures.

RESULTS

Homeless participants trended toward poorer ratings for all HCAHPS subscales, reaching significance for the Communication about Medications subscale, with a mean score 1.2 (95% CI 0.48-1.76) points lower compared to non-homeless sample. Length of stay was not significantly different between homeless and non-homeless participants.

CONCLUSION

In an urban safety-net hospital, disparities in communications regarding medications between hospital staff and patients were found based on housing status.

Health Care Utilization of Individuals Affected by Homelessness: Illinois, 2011-2018

OBJECTIVES

To describe individuals coded as homeless in state-level data comprising of outpatient and inpatient cases over a multi-year period to provide public health surveillance data on the health care utilization and needs of this population.

RESEARCH DESIGN

In this cross-sectional study, outpatient and inpatient visits coded for homelessness were identified from the Illinois Hospital Discharge Database from January 1, 2011 through December 31, 2018. Demographic characteristics, primary diagnosis and comorbid conditions, and hospital course of treatment were described. Predictors of discharge to a health care facility versus routine discharge to home or self-care were evaluated using multivariable logistic regression.

RESULTS

There were 154,173 patient visits predominantly involving males, those aged 25-64 years, and non-Hispanic Whites and African Americans. The majority had comorbidities of depression, psychosis, and/or substance abuse (70.2%) and a routine discharge to home or self-care (81.9%). Discharge to home or self-care relative to another health care institution was associated with having charity coverage and being Black/African American.

CONCLUSIONS

Those experiencing homelessness experience a high burden of health concerns. Hospital billing records can be used to prioritize the distribution of limited public health resources for health care programs and interventions among those experiencing homelessness.

Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department

Introduction

Our objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED.

Methods

We surveyed patients in an urban, safety-net ED from June–August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents.

Results

Of those surveyed, 35% (95% confidence interval [CI], 31–38) identified as homeless and 28% (95% CI, 25–31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29–64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24–64) with unstable housing presenting over the next eight hours.

Conclusion

The ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed

Homelessness in Pediatric Populations: Strategies for Prevention, Assistance, and Advocacy

Recent data indicate that homelessness among pediatric and adolescent populations is significantly higher than previous studies and point-in-time counts indicate. Pediatricians and other health care providers often see children and youth who are at risk of or are currently experiencing homelessness, but may not be aware of their status. This article summarizes current definitions of homelessness and data on common health issues for pediatric patients. Information on how to recognize and help those experiencing homelessness as well as areas for continued advocacy is shared.

Street Medicine: Creating a "Classroom Without Walls" for Teaching Population Health

"Street Medicine" programs provide medical care to homeless populations outside of traditional healthcare institutions, literally on the street and in transitional settings where unsheltered homeless people live. Such programs are emerging around the world often based at medical schools and primary care residency programs, and can provide ideal frameworks for twenty-first century "Classrooms Without Walls" aimed at improving Population Health. We provide a 12-step blueprint for creating a Street Medicine program in the context of a medical teaching institution.

Homelessness Among Patients in a Southeastern Safety Net Emergency Department

OBJECTIVES

Emergency departments (EDs) are important providers for homeless individuals, providing vital health care and meeting the subsistence needs of many homeless patients (eg, food, water, shelter). Studies that have examined the proportion of patients in the ED setting who experience homelessness have been conducted primarily in the northeastern United States. We hypothesized that findings from prior studies, conducted primarily in the Northeast, would not generalize to other regions of the United States. We conducted a direct patient survey to describe the proportion and demographics of ED patients who have experienced homelessness within the past 12 months in an urban safety net hospital in Atlanta, Georgia.

METHODS

A cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016. A team of trained research assistants administered a structured survey instrument to patients who were 18 years old, English speakers, not incarcerated, and able to provide informed consent. Questions were based on the US Department of Health and Human Services definition of homelessness.

RESULTS

A total of 923 ED patients (55.1% male; median age 44 years) completed the survey. Of the ED patients surveyed, 51.5% reported some measure of homelessness in the past 12 months: lived with others but did not pay rent (n = 279, 30.2%), skipped mortgage or rent payment (n = 111, 12%), experienced eviction (n = 74, 8%), lived in a hotel or motel (n = 196, 21.2%), lived in a place not meant for human habitation (n = 76, 8.2%), slept in a shelter (n = 131, 14.2%), and slept on the street (n = 115, 12.5%). Men (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.17-2.09), patients who completed some school (OR 2.85, 95% CI 1.72-4.71), and patients who completed high school (OR 2.32, 95% CI 1.53-3.52) were more likely to have experienced homelessness in the 12 months preceding their ED visit.

CONCLUSIONS

The rate of patients experiencing homelessness at our hospital is substantially greater than those reported in prior surveys of ED patients. More research is needed on homelessness and its implications for ED patients.

Making sense of street chaos: an ethnographic exploration of homeless people's health service utilization

Background

Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population.

Methods

Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data.

Results

Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma.

Conclusions

An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.

Effect of Selective Serotonin Reuptake Inhibitors on Healthcare Utilization in Patients with Post-Traumatic Stress Disorder and Alcohol Use Disorder

Aims

The objective of this study is to address equivocation in estimates of selective serotonin reuptake inhibitor initiation (SSRI) effect on all-cause and alcohol-related ER visits, and medical or psychiatric admissions within 2 years of initial Post-Traumatic Stress Disorder (PTSD) diagnosis in patients with PTSD and Alcohol Use Disorder (AUD).

Methods

This study is a quasi-experimental, new-user-design cohort study of 3235 patients seen at the VA North Texas Healthcare System between January 1, 2000 and December 31, 2016. High dimensional propensity score (HDPS) techniques were used to estimate likelihood of SSRI initiation within 30 days of first PTSD diagnosis. Propensity scores were used to calculate weights for likelihood of SSRI initiation which were used to control for baseline covariates in estimations of SSRI medication effect on odds of each outcome occurring.

Results

Compared to those who did not receive SSRIs, patients prescribed an SSRI within 30 days showed significantly lower odds of alcohol-related ER visits (OR=0.668, 95%CI = 0.476 to 0.938, P = 0.02) and alcohol-related medical admissions (OR=0.583, 95%CI = 0.399 to 0.851, P = 0.005).

Limitations

Inconsistent assessment of PTSD severity necessitated the use of HDPS models to control for baseline confounding. Our study design mimicked intent-to-treat trial design and therefore could not control for SSRI initiations after the 30-day grace period following initial PTSD diagnosis.

Conclusions

SSRI initiation in patients with AUD and PTSD is associated with significantly reduced odds of alcohol-related medical hospitalization and alcohol-related ER visits within 2 years of first PTSD diagnosis. Additional studies are needed to verify these results.

Prevalence of Homelessness by Gender in an Emergency Department Population in Pennsylvania

Context

According to the US Department of Housing and Urban Development, nearly 1.5 million people spend at least 1 night in an emergency shelter or transitional housing each year, and more than 500,000 people are homeless on a given night in the United States. To our knowledge, limited data exist regarding the prevalence of homelessness in ED patients by gender (male, female, and transgender).

Objective

To assess the prevalence of homelessness by gender in 3 EDs in Pennsylvania.

Methods

From May 2015 through February 2016, patients in 3 EDs were approached to take a 5-question homelessness screening survey. To participate, patients had to be aged at least 18 years, speak English, have capacity to complete the survey, be willing to participate, and not be critically ill. Frequency comparisons were made using χ2 analysis. Statistical significance was defined as P≤.05.

Results

A total of 4395 patients were included in the analysis. The mean (SD) age of the participants was 50.8 (20.5) years; 2557 (58.2%) were women and 3 (0.07%) were transgender. No difference in the rate of homelessness was observed between men and women, with 135 of 1835 men (7.4%) and 173 of 2557 women (6.8%) screening positive for homelessness (P=.472). Forty of 2557 women (1.6%) and 41 of 1835 men (2.2%) admitted they had slept outside or in an abandoned building, their car, an emergency shelter, or a hotel due to financial hardship in the past 60 days (P=.26). One transgender patient screened positive for homelessness. The mean age of participants who screened positive for homelessness was 40.9 (15.9) years.

Conclusion

No significant difference was observed in the rate of homelessness between men and women in this ED population, which defies the perception that this issue primarily affects men. Public health interventions aimed at homeless populations should consider that both men and women may be equally affected by homelessness.

Material Needs of Emergency Department Patients: A Systematic Review

BACKGROUND

Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.

METHODS

We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.

RESULTS

Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.

CONCLUSIONS

Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.