Prof. Byrne’s New Research May Help Prevent Homelessness for ER Patients
With the number of people experiencing homelessness continuing to rise, prevention is one powerful way to address the crisis. By identifying who is at risk of housing insecurity, medical professionals can better direct patients to homelessness prevention services. New research, led by Prof. Thomas Byrne from BU School of Social Work (BUSSW) and published in JAMA Network, illustrates the potential value of screening emergency room patients for risk of future homelessness.
The Connection Between Housing Instability, Poorer Health, & Emergency Care
Without adequate housing, people are more likely to experience worse physical and mental health. Studies also show that emergency department (ED) patients are more likely to experience housing insecurity than other admitted patients because many do not have access to other forms of health care. “However, prior research on screening tools for housing instability have focused largely on outpatient or pediatric settings, with limited attention to the ED setting,” say the authors. By screening ED patients, researchers hope to capture an important group that has been overlooked in the past.
Addressing the Screening Gap with Two Single-Item Questions
Due to the hectic nature of emergency care, the researchers tested two different screening tools, each comprised of just a single question:
- Are you worried or concerned that in the next 2 months you may not have stable housing that you own, rent, or stay in as part of a household? (Answer yes or no)
- How likely do you think it would be that you would have to use a homeless shelter in the next 6 months? (Answer from very unlikely to very likely)
Since the study took place in New York City, which has a legal right to emergency shelter, the latter question may be less relevant to other locations where shelter is less available. More research is needed to test the effectiveness of alternative phrasing.
Collecting Voluntary Private Information to Understand Homelessness Risk
The two screening questions were influenced by the belief that individuals are the best judges of their own future risk of homelessness, due to hard-to-measure “private information” about their housing situation. Ultimately, the questions performed similarly in predicting future homelessness to other tools that rely on “public information,” such as individuals’ prior history of shelter use, health care utilization, or involvement with the criminal justice system. “Private information is complex and fully knowable only to a given individual,” the authors explain. “Our findings highlight the inherent challenges in identifying future homelessness, including for patients themselves.”
Even so, this screening did reveal patients who were more likely to experience homelessness:
- 25% of the participants indicated that they were at risk of homelessness in the next two months.
- Of those patients who said they were at risk, 6% entered a shelter 2 months after their ED visit, 9% after 6 months, and 12% after 12 months.
- Of those who did not indicate they were at risk, only 1% entered a shelter after 2 months or 6 months, and 2% entered a shelter after 12 months.
By using more formal methods for assessing the performance of their questions, the authors found that both questions performed moderately well in predicting future risk of homelessness.
Future Research
Though this study showed promising results for identifying a patient’s risk of homelessness, the authors stress that this is only the first step in actually using these questions in practice. For instance, a study could incorporate this screening into real-world ED workflows to identify patients at high-risk of homelesnsess and connect them with appropriate services. “Important questions remain about who should ask such questions and when, how information should be documented, and whether there may be unintended consequences.”
The paper was co-authored by Mindy Hoang from the University of Cincinnati College of Medicine; Ann Elizabeth Montgomery, PhD, from the University of Alabama at Birmingham School of Public Health; Eileen Johns, PhD, from the New York City Center for Innovation through Data Intelligence; Marybeth Shinn, PhD from Peabody College at Vanderbilt University; Tod Mijanovich, PhD, from New York University Steinhardt School; Dennis Culhane, PhD, from the University of Pennsylvania School of Social Policy and Practice; and Kelly M. Doran, MD, MHS, from New York University School of Medicine.