ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use.

BACKGROUND: Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use. METHODS: We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months. RESULTS: Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention. CONCLUSIONS: This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

Development of a homelessness risk screening tool for emergency department patients.

OBJECTIVE: To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes. DATA SOURCES: Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database. STUDY DESIGN: Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires. DATA COLLECTION/EXTRACTION METHODS: Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching. PRINCIPAL FINDINGS: Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry. CONCLUSIONS: Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.

Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis.

STUDY OBJECTIVE: Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. METHODS: We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. RESULTS: Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. CONCLUSION: In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

Efficient targeting of homelessness prevention services for families.

OBJECTIVES: We developed and evaluated a model to target homelessness prevention services to families more efficiently. METHODS: We followed 11,105 families who applied for community-based services to prevent homelessness in New York City from October 1, 2004, to June 30, 2008, through administrative records, using Cox regression to predict shelter entry. RESULTS: Over 3 years, 12.8% of applicants entered shelter. Both the complete Cox regression and a short screening model based on 15 risk factors derived from it were superior to worker judgments, with substantially higher hit rates at the same level of false alarms. We found no evidence that some families were too risky to be helped or that specific risk factors were particularly amenable to amelioration. CONCLUSIONS: Despite some limitations, an empirical risk model can increase the efficiency of homelessness prevention services. Serving the same proportion of applicants but selecting those at highest risk according to the model would have increased correct targeting of families entering shelter by 26% and reduced misses by almost two thirds. Parallel models could be developed elsewhere.