Unsheltered Homelessness Associated with Increased Emergency Department Visits

A study published in the Journal of Health Care for the Poor and Underserved explores the relationship between different types of housing insecurity – such as overcrowding, frequent moves, and homelessness – and the use of emergency departments (EDs) for medical care. The researchers find that homelessness was associated with a significantly higher number of ED visits. The researchers also find that only unsheltered homelessness was associated with increased ED use. Homeless patients who were consistently sheltered showed no difference in ED use compared to housed patients.  

The researchers recruited study participants from an urban, public hospital in New York City between November 2016 and January 2018. They surveyed participants about past and current housing status, past hospital use, physical and emotional health, and other economic indicators. Housing status was divided into five major categories: (1) homelessness (was sheltered or unsheltered in the past year); (2) unaffordable housing (owed rent arrears or did not pay the full rent during the past year); (3) overcrowded housing (lived with more than two people per bedroom); (4) forced move (experienced formal or informal eviction in the past year); and (5) multiple moves (lived in three or more places in the past year). Participants could report more than one type of housing insecurity. Researchers linked survey data to a state-level, longitudinal administrative dataset that tracked emergency department visits, admission and discharge dates, and diagnoses.

Of the nearly 1,800 patients in the sample, 51% reported at least one form of housing insecurity. The most common forms of housing insecurity were homelessness (22%) and unaffordable housing (21%). Nearly 15% reported a recent forced move and 14% reported three or more moves in the past year. Researchers found a substantial overlap between housing-insecure categories, particularly homelessness, forced moves, and multiple moves. Patients experiencing homelessness reported the highest rates of physical and mental health diagnoses as well as the highest rates of involvement with the criminal legal system. Those reporting homelessness were also disproportionately Black and male.

The researchers found that after controlling for other factors, those who reported experiencing homelessness were nearly twice as likely to have an ED visit in the year after the survey than their counterparts who reported no homelessness. Specifically, unsheltered homelessness was associated with significantly higher ED use in the year after the survey. Those who reported being unsheltered for at least one night in the past year were nearly three times as likely to have an ED visit in the year after their baseline survey compared to those not experiencing homelessness. Homeless patients who were currently or consistently sheltered showed no difference in ED use from housed patients.

The researchers proposed several potential explanations for the relationship between unsheltered homelessness and increased ED use. People experiencing unsheltered homelessness had a wide range of conditions that brought them to the emergency room, many of which were related to the challenges of living on the street, such as a lack of access to hygiene resources. Individuals who remain unsheltered may also have more complex health and social needs that are not well met within the shelter system. The lack of a relationship between sheltered homelessness and ED use may reflect better access to health care services through referrals from shelter staff or onsite medical care, although access to these services is not universal.

The researchers note that their findings provide further evidence for strengthening policies that prevent and alleviate homelessness, particularly unsheltered homelessness. They note that Housing First is shown to improve housing retention and stability among formerly homeless individuals. Further, high-quality shelters may prevent increased ED use in some cases. Lastly, researchers call for better state, local, and federal data on evictions, forced moves, and homelessness linked with health data to better understand the relationship between housing instability and health outcomes.

Read the full report at: https://tinyurl.com/32fm54kj