Original Article

Homelessness Among Patients in a Southeastern Safety Net Emergency Department

Authors: Toni S. Jackson, MD, Tim P. Moran, PhD, Jonathan Lin, BS, Jeremy Ackerman, MD, PhD, Bisan A. Salhi, MD, PhD

Abstract

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.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Henry M, Watt R, Rosenthal L, et al. The 2017 Annual Homeless Assessment Report to Congress. Washington, DC: Department of Housing and Urban Development Office of Community Planning and Development; 2017.
2. Morris DM, Gordon JA. The role of the emergency department in the care of homeless and disadvantaged populations. Emerg Med Clin North Am 2006;24:839-848.
3. Salhi BA, White MH, Pitts SR, et al. Homelessness and emergency medicine: a review of the literature. Acad Emerg Med 2018;25:577-593.
4. Gordon JA, Chudnofsky CR, Hayward RA. Where health and welfare meet: social deprivation among patients in the emergency department. J Urban Health 2001;78:104-111.
5. Rodriguez RM, Fortman J, Chee C, et al. Food, shelter and safety needs motivating homeless persons’ visits to an urban emergency department. Ann Emerg Med 2009;53:598-602.
6. Gordon JA. The hospital emergency department as a social welfare institution. Ann Emerg Med 1999;33:321-325.
7. O’Toole TP, Conde-Martel A, Gibbon JL, et al. Where do people go when they first become homeless? A survey of homeless adults in the USA. Health Soc Care Community 2007;15:446-453.
8. Pearson DA, Bruggman AR, Haukoos JS. Out-of-hospital and emergency department utilization by adult homeless patients. Ann Emerg Med 2007;50:646-652.
9. Ku BS, Scott KC, Kertesz SG, et al. Factors associated with use of urban emergency departments by the U.S. homeless population. Public Health Rep 2010;125:398-405.
10. Brown RT, Steinman MA. Characteristics of emergency department visits by older versus younger homeless adults in the United States. Am J Public Health 2013;103:1046-1051.
11. Coe AB, Moczygemba LR, Harpe SE, et al. Homeless patients’ use of urban emergency departments in the United States. J Ambul Care Manag 2015;38:48-58.
12. Tadros A, Layman SM, Brewer MP, et al. A 5-year comparison of emergency department visits by homeless and non-homeless patients. Am J Emerg Med 2016;34:805-808.
13. Doran KM, Kunzler NM, Mijanovich T, et al. Homelessness and other social determinants of health among emergency department patients. J Soc Distress Homeless 2016;25:71-77.
14. Feldman BJ, Calogero CG, Elsayed KS, et al. Prevalence of homelessness in the emergency department setting. West J Emerg Med 2017;18:366-372.
15. Bisgaier J, Rhodes KV. Cumulative adverse financial circumstances: associations with patient health status and behaviors. Health Soc Work 2011;36:129-137.
16. Hanley O, Miner J, Rockswold E, et al. The relationship between chronic illness, chronic pain, and socioeconomic factors in the ED. Am J Emerg Med 2011;29:286-292.
17. Stevens TB, Richmond NL, Pereira GF, et al. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med 2014;21:651-658.
18. Fryling LR, Mazanec P, Rodriguez RM. Barriers to homeless persons acquiring health insurance through the Affordable Care Act. J Emerg Med 2015;49:755-762.e2.
19. Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’ frequent users. Acad Emerg Med 2000;7:637-646.
20. Murray C, Schuetz J. Housing in the US Is Too Expensive, Too Cheap, or Just Right. It Depends on Where You Live. Washington, DC:Brookings Institute;2018.
21. National Health Care for the Homeless Council. Frequently Asked Questions About Health Care for the Homeless. In: Administration HRaS , ed. Nashville, TN 2011.
22. Little RJA. A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc 1988;83:1198-1202.
23. Newgard CD, Haukoos JS. Advanced statistics: missing data in clinical research-part 2: multiple imputation. Acad Emerg Med 2007;14:669-678.
24. Van Buuren S, Brand JP, Groothuis-Oudshoorn C, et al. Fully conditional specification in multivariate imputation. J Stat Comput Simul 2006;76: 1049-1064.
25. Centers for Disease Control and Prevention. 2013 NHAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc13_ed.pdf. Published 2013. Accessed October 24, 2017.
26. Doran KM, Vashi AA, Platis S, et al. Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless. Am J Public Health 2013;103(suppl 2):S355-S360.
27. Holmes N, Berube A. City and metropolitan inequality on the rise, driven by declining incomes. https://www.brookings.edu/research/city-and-metropolitan-inequality-on-the-rise-driven-by-declining-incomes. Published January 14, 2016. Accessed July 6, 2019.
28. Kanell ME. Atlanta rent growth among nation’s fastest. https://www.ajc.com/business/atlanta-rent-growth-among-nation-fastest/fZ7DCMDwjEjiH004ZqzP1L. Published March 26, 2018. Accessed March 20, 2019.
29. Immergluck D, Carpenter A, Lueders A. Declines in low-cost rented housing units in eight large southeastern cities. https://saportareport.com/wp-content/uploads/2016/05/Georgia-Tech-declines-in-low-cost-housing.pdf. Published May 2016. Accessed March 20, 2019.
30. Baggett TP, Hwang SW, O'Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med 2013;173:189-195.
31. Culhane DP, Metraux S, Byrne T, et al. The aging of contemporary homelessness. https://works.bepress.com/dennis_culhane/119/download. Published June 2012. Accessed July 6, 2019.
32. Hwang SW, Dunn JR. Homeless people. In: Galea S, Vlahov D, eds. Handbook of Urban Health: Populations, Methods, and Practice. New York: Springer; 2005:19-41.
33. Bachrach D, Pfister H, Wallis K, et al. Addressing patients’ social needs: an emerging business case for provider investment. https://www.commonwealthfund.org/publications/fund-reports/2014/may/addressing-patients-social-needs-emerging-business-case-provider. Published May 29, 2014. Accessed July 6, 2019.
34. Williams M. Can we measure homelessness? A critical evaluation of 'capture-recapture.' Methodol Innovat 2010;5:49-59.
35. Montgomery AE, Fargo JD, Byrne TH, et al. Universal screening for homelessness and risk for homelessness in the Veterans Health Administration. Am J Public Health 2013;103(suppl 2):S210-S211.
36. Gottlieb LM, Tirozzi KJ, Manchanda R, et al. Moving electronic medical records upstream: incorporating social determinants of health. Am J Prev Med 2015;48:215-218.
37. Fargo JD, Montgomery AE, Byrne TH, et al. Needles in a haystack: screening and healthcare system evidence for homelessness. Stud Health Technol Inform 2017;235:574-578.