Systematically screening patients for homelessness in the emergency department could help address America's homelessness epidemic while improving patient care and freeing up ED capacity.
Maria Raven, MD, an associate professor of emergency medicine and the chief of emergency medicine and the vice chair of emergency medicine at University of California-San Francisco (UCSF), said emergency physicians see firsthand the challenges that homeless patients face, giving them a perspective many other health care professionals don't have.
“Homelessness is a social determinant of health, and it really is in our wheelhouse to confront this issue and to help address it,” Dr. Raven said. “The emergency department is probably an underutilized point of intervention to try to help people who are experiencing homelessness.”
Writing in Annals of Emergency Medicine, she said screening for and identifying homelessness among ED patients is the first step in providing the data needed to support health system-based initiatives to address homelessness in their communities. (2019;74[5S]:S33; https://bit.ly/3cv535x.) Screening can also lead to linking an individual patient to housing and other support services, said Aisha Terry, MD, MPH, an associate professor of emergency medicine and health policy at George Washington University.
“Practically speaking, undomiciled emergency department patients whose social needs are not adequately addressed tend to continue to visit the ED as if through a revolving door,” said Dr. Terry. “So it makes sense for emergency medicine, which is uniquely positioned to touch this population, to be interested in addressing homelessness. It is beneficial not just to the patient but to the health care system as a whole.”
The prevalence of homelessness among ED patients varies among hospitals and, at a national level, is not fully understood, Dr. Terry said. A study conducted in three EDs, all part of the same health system in northeastern Pennsylvania, found that seven percent of ED patients were experiencing homelessness and 3.1 percent were at risk for homelessness. (West J Emerg Med. 2017;18366; https://bit.ly/35UFg4t.)
The proportion of patients who were homeless or at risk was highest—18.7 percent—at the health system's small inner-city hospital. That proportion was 9.1 percent at its suburban community hospital and 7.5 percent at its Level 1 suburban trauma center. Notably, researchers found the prevalence of current homelessness in the summer months—7.5 percent at the three sites together—was similar to the winter months, when 6.6 percent of patients were homeless.
Beginning in 2019, California hospitals have been mandated by state law to ask ED patients and inpatients about their housing status. Based on their answers, the hospital must document the resources, such as food and clothing, provided to the patient and the discharge destination. Hospitals are responding to the mandate in various ways, Dr. Raven said, because there is no standard or best practice for screening yet.
At UCSF's ED, the bedside nurse uses a two-question screening tool developed for use by the Department of Veterans Affairs (March 2014; https://bit.ly/3cPie1f):
- In the past two months, have you been living in stable housing that you own, rent, or stay in as part of a household?
- Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as part of a household?
The responses are entered into the patient's electronic medical record. Those experiencing homelessness or who are at risk are connected to a health care navigator and a social worker designated to help UCSF comply with the state mandate. “They do a lot of work with these patients,” Dr. Raven said. “That makes this easier [for the department] because then we are not asking the physicians or nurses to do that more in-depth work.”
Beyond California, several hospitals and health systems have begun routinely screening for homelessness and other social determinants of health in their outpatient clinics, but most EDs are not yet following suit, said Kelly Doran, MD, an assistant professor of emergency medicine and population health at NYU Langone Health. Emergency physicians alone should not be expected to solve the problem of homelessness, she said, but ED screening data can support their health systems' housing initiatives or encourage their system leaders to partner with community organizations working to address homelessness.
Regardless of whether an ED has a formal screening program, Dr. Doran said knowing a patient's housing status is important for EPs. “Should homelessness be something that a physician asks patients about in the emergency department? To that question, I tend to say yes,” she said. “Completely independent of whether you are trying to solve their homelessness, knowing that someone is homeless can influence your treatment plan.”
Knowing that a person lacks housing, for example, might trigger a decision to admit a patient rather than discharge him. Or it might prompt a decision to prescribe a once-daily medication rather than multiple doses per day.
Beyond screening, routine use of the ICD-10 codes for homelessness, inadequate housing, and other problems related to housing could improve patient care because all of a patient's health care providers could see that housing instability was a potential issue. And it would improve the quality of data researchers use to study homelessness among ED patients, Dr. Doran said. But some patients might not want to have those codes in their medical records, fearing that they might be stigmatized by other providers.
“If you talk to people who are homeless, they will often recount experiences where they have been treated differently from other patients in the health care system,” she said. “Sometimes when providers hear that someone is homeless, they make assumptions—‘oh, they're just in the ED because they want a sandwich or they want a place to sleep’—and they may pay less attention to what is often a very real medical complaint that the person has. So if we started putting these codes in the chart, it should be paired with education for providers and other efforts to reduce stigma.”
Ms. Butchercovers health care policy and business of health care issues, trends, and controversies for publications read by physicians, health system leaders, and the public. She is a member of the Association of Health Care Journalists. Follow her on Twitter@lolabutcher.