Performance of 2 Single-Item Screening Questions to Identify Future Homelessness Among Emergency Department Patients.

Importance: Despite increasing interest in assessing patient social needs in health care settings, there has been little research examining the performance of housing-related screening questions. Objective: To examine the performance of 2 single-item screening questions assessing emergency department (ED) patients' self-perceived risk of future homelessness. Design, Setting, and Participants: This prospective cohort study was conducted among a randomly selected sample of adult ED patients from 2016 to 2017 in a public hospital ED in New York City. Data were analyzed from September 2019 through October 2021. Exposures: Responses on patient surveys conducted at the baseline ED visit for 2 single-item screening questions on self-perceived risk for future housing instability and homelessness were collected. One question asked patients if they were worried about having stable housing in the next 2 months, and the other question asked them to rate the likelihood that they would enter a homeless shelter in the next 6 months. Outcomes: Homeless shelter entry 2, 6, and 12 months after an ED visit, assessed using shelter administrative data in the study city, which was linked with participant baseline survey responses. Results: There were 1919 study participants (976 [51.0%] men and 931 [48.6%] women among 1915 individuals with gender data; 700 individuals aged 31-50 years [36.5%] among 1918 individuals with age data; 1126 Hispanic or Latinx individuals [59.0%], 368 non-Hispanic Black individuals [19.3%], and 225 non-Hispanic White individuals [11.8%] among 1908 individuals with race and ethnicity data). Within 2, 6, and 12 months of the ED visit, 45 patients (2.3%), 66 patients (3.4%), and 95 patients (5.0%) had entered shelter, respectively. For both single-item screening questions, participants who answered affirmatively had significantly higher likelihood of future shelter entry at each time point examined (eg, at 2 months: 31 participants responding yes [6.5%] vs 14 participants responding no [1.0%] to the question concerning being worried about having stable housing in the next 2 months). Sensitivity of the screening questions ranged from 0.27 to 0.69, specificity from 0.76 to 0.97, positive predictive value from 0.07 to 0.27, and area under the receiver operating characteristic curve from 0.62 to 0.72. Conclusions and Relevance: This study found that 2 single-item screening questions assessing ED patient self-perceived risk of future housing instability and homelessness had adequate to good performance in identifying risk for future shelter entry. Such single-item screening questions should be further tested before broad adoption.

Leveraging integrated data for program evaluation: Recommendations from the field.

Use of administrative data to inform decision making is now commonplace throughout the public sector, including program and policy evaluation. While reuse of these data can reduce costs, improve methodologies, and shorten timelines, challenges remain. This article informs evaluators about the growing field of Integrated Data Systems (IDS), and how to leverage cross-sector administrative data in evaluation work. This article is informed by three sources: a survey of current data integration efforts in the United States (U.S.) (N=63), informational interviews with experts, and internal knowledge cultivated through Actionable Intelligence for Social Policy's (AISP) 12+ years of work in the field. A brief discussion of the U.S. data integration context and history is provided, followed by discussion of tangible recommendations for evaluators, examples of evaluations relying on integrated data, and a list of U.S. IDS sites with publicly available processes for external data requests. Despite the challenges associated with reusing administrative data for program evaluation, IDS offer evaluators a new set of tools for leveraging data across institutional silos.

Moving on trial: protocol for a pilot randomised controlled trial of models of housing and support to reduce risks of COVID-19 infection and homelessness.

BACKGROUND: It is estimated that around 160,000 households in Britain experience homelessness each year, although no definitive statistics exist. Between March and September 2020, as part of the initial 'Everyone In' government response to COVID-19 in England, 10,566 people were living in emergency accommodation and nearly 18,911 people had been moved into settled accommodation. However, some forms of temporary accommodation may not be suitable as shared facilities make it impossible for people to adhere to government guidelines to reduce the spread of COVID-19. METHODS: This is parallel group, pilot randomised controlled trial. The target is to recruit three local authorities, each of which will recruit 50 participants (thus a total of approximately 150 participants). Individuals are eligible if they are aged 18 and over, in a single-person homeless household, temporarily accommodated by the LA with recourse to public funds. Participants will be randomised to receive settled accommodation (intervention group) or temporary accommodation (control group). The intervention group includes settled housing such as Private Rented Sector (low and medium support), Social Housing (low and medium support), and Housing First (High support). The control group will maintain treatment as usual. The follow-up period will last 6 months. The primary outcome is to assess the feasibility of recruitment, retention, and acceptability of trial processes against progression criteria laid out in a traffic light system (green: all criteria are met, the trial should progress as designed in this pilot; amber: the majority of criteria are met and with adaptations to methods all criteria could be met; red: the minority of criteria are met and the pilot RCT should not proceed). Secondary outcomes include assessment of completeness of data collection at 3 and 6 months and percentage of participants consenting to data linkage, as well as a process evaluation and economic evaluation. DISCUSSION: This trial will address feasibility questions associated with progression to a fully powered effectiveness trial of models of housing to reduce risk of COVID-19 infection and homelessness. TRIAL REGISTRATION: ISRCTN69564614 . Registered on December 16, 2020.

Association Between Registered Sex Offender Status and Risk of Housing Instability and Homelessness among Veterans.

Research is limited about whether and to what extent registered sex offenders (RSOs) face an increased risk of housing instability. The intersection of RSO and housing instability is particularly salient for veterans as there are disproportionately higher rates of veterans among both RSOs and homeless populations. This study assessed the relationship between RSO status and risk of housing instability and homelessness among military veterans. We matched a list of 373,774 RSOs obtained from publicly available sex offender registries in 19 states with a cohort of 5.9 million veterans who responded to a brief screening for housing instability administered throughout the Veterans Health Administration between 2012 and 2016. Logistic regression estimated adjusted odds of any housing instability and homelessness among veterans identified as RSOs. Veterans identified as RSOs had 1.81 (95% confidence interval [CI] 1.46-2.25) and 2.97 (95% CI 1.67-5.17) times greater odds of reporting any housing instability and homelessness, respectively, than non-RSOs. Findings represent some of the strongest evidence to date for the high risk of housing instability and homelessness among RSOs, suggesting a clear gap in policy and programmatic responses to their unique housing needs. Evidence-based alternative approaches to residence restriction laws may reduce recidivism and protect public safety.

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.

At the Intersection of Homeless Encampments and Heroin Addiction: Service Use Barriers, Facilitators, and Recommendations from the City of Philadelphia's Encampment Resolution Pilot.

We provide an overview of the pilot and evaluation measures used for an independent evaluation of the Encampment Resolution Pilot (ERP) wherein the City of Philadelphia closed two homeless encampments in May 2018 and sought to assist those displaced by the closures with housing and treatment services. The evaluation used the Rapid Assessment, Response, and Evaluation method to collect qualitative findings on service use barriers and facilitators from open-ended interviews with people staying in the encampments (N = 27) and service providers (N = 10). We assessed how the ERP allowed providers to "push the system" by removing access barriers, and providing amenable, effective, and accessible housing and drug treatment services that led to more widely adopted best practices. However, there was a clear need for additional supportive services and aftercare for those exiting treatment. Providers also cited a need for more integrated medical and mental health services.

Association of Homelessness with Hospital Readmissions-an Analysis of Three Large States.

BACKGROUND: Individuals experiencing homelessness have higher hospitalization and mortality rates compared with the housed. Whether they also experience higher readmission rates, and if readmissions vary by region or cause of hospitalization is unknown. OBJECTIVE: Evaluate the association of homelessness with readmission rates across multiple US states. DESIGN: Retrospective analysis of administrative claims PATIENTS: All inpatient hospitalizations in Florida, Massachusetts, and New York from January 2010 to October 2015 MAIN MEASURES: Thirty- and 90-day readmission rates KEY RESULTS: Out of a total of 23,103,125 index hospitalizations, 515,737 were for patients who were identified as homeless at the time of discharge. After adjusting for cause of index hospitalization, state, demographics, and clinical comorbidities, 30-day and 90-day readmission rates were higher for index hospitalizations in the homeless compared with those in the housed group. The difference in 30-day readmission rates between homeless and housed groups was the largest in Florida (30.4% vs. 19.3%; p < 0.001), followed by Massachusetts (23.5% vs. 15.2%; p < 0.001) and New York (15.7% vs. 13.4%; p < 0.001) (combined 17.3% vs. 14.0%; p < 0.001). Among the most common causes of hospitalization, 30-day readmission rates were 4.1 percentage points higher for the homeless group for mental illness, 4.9 percentage points higher for diseases of the circulatory system, and 2.4 percentage points higher for diseases of the digestive system. CONCLUSIONS: After adjusting for demographic and clinical characteristics, homelessness is associated with significantly higher 30- and 90-day readmission rates, with a significant variation across the three states. Interventions to reduce the burden of readmissions among individuals experiencing homelessness are urgently needed. Differences across states point to the potential of certain public policies to impact health outcomes for individuals experiencing homelessness.

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.

When Crises Converge: Hospital Visits Before And After Shelter Use Among Homeless New Yorkers.

People who are homeless use more hospital-based care than average, yet little is known about how hospital and shelter use are interrelated. We examined the timing of emergency department (ED) visits and hospitalizations relative to entry into and exit from New York City homeless shelters, using an analysis of linked health care and shelter administrative databases. In the year before shelter entry and the year following shelter exit, 39.3 percent and 43.3 percent, respectively, of first-time adult shelter users had an ED visit or hospitalization. Hospital visits-particularly ED visits-began to increase several months before shelter entry and declined over several months after shelter exit, with spikes in ED visits and hospitalizations in the days immediately before shelter entry and following shelter exit. We recommend cross-system collaborations to better understand and address the co-occurring health and housing needs of vulnerable populations.

Suicidality and the Onset of Homelessness: Evidence for a Temporal Association From VHA Treatment Records.

OBJECTIVE: This study examined the temporal sequencing of a first-recorded episode of homelessness and treatment for suicidal ideation or attempt. METHODS: Data were from the U.S. Department of Veterans Affairs Corporate Data Warehouse and contained medical records of service use dates and associated ICD codes for care provided by the Veterans Health Administration. The analysis examined treatment for suicidality before and after a first record of homelessness ("onset") among 152,519 veterans. The second analysis examined the rate of treatment for suicidality among 156,288 veterans with any indication of homelessness. The third analysis examined the rate of homelessness among 145,770 veterans with indication of suicidality. RESULTS: Among newly homeless veterans, treatment for suicidality peaked just before onset of homelessness. Thirteen percent of homeless veterans had evidence of suicidality. Twenty-nine percent of veterans with evidence of suicidality appeared to have concurrent homelessness. CONCLUSIONS: Homelessness should be considered a primary risk factor for suicidality.

Gender Differences in Factors Associated with Unsheltered Status and Increased Risk of Premature Mortality among Individuals Experiencing Homelessness.

BACKGROUND: Among individuals experiencing homelessness, unsheltered status is associated with poor health and access to care and an increased risk for premature death. Insufficient research has explored gender differences in these outcomes; the objective of this study was to address this gap in the research. METHODS: This study used survey data collected during the 100,000 Homes Campaign. Chi-square tests identified differences in the characteristics of women, men, and transgender individuals. Generalized linear mixed models fit with demographic, homelessness, mental/behavioral health, institutional, and income characteristics were run separately for women and men to assess correlates of unsheltered status and increased risk of premature mortality. RESULTS: Men reported more frequently experiencing unsheltered homelessness while women and transgender participants more frequently met the criteria for risk of premature mortality. Women reported less frequently than men a history of or current substance use, but it significantly increased their likelihood of unsheltered homelessness; reports of mental health issues were rarer among men but significantly increased their odds of unsheltered homelessness. The experience of a violent attack while homeless was most strongly related to increased risk of premature mortality for both women and men. CONCLUSIONS: Interventions to reduce unsheltered homelessness among men should be particularly sensitive to mental health issues while for women there may need to be increased attention to substance use. A focus on experience of trauma and the provision of trauma-informed care is essential to address the increased risk of premature mortality among both men and women experiencing homelessness.

Posthumously Assessing a Homeless Population: Services Use and Characteristics.

OBJECTIVE: Data on services use, characteristics, and geographic distribution of homeless individuals who died in Philadelphia from 2009 to 2011 provided perspective on assessments of the homeless population that rely on conventional counts and surveys. METHODS: Data from the City of Philadelphia Medical Examiner's Office were used to parse homeless decedents into three groups on the basis of use of homelessness services (known users, occasional users, and nonusers), and differences among the groups were assessed by using descriptive and multivariate methods. RESULTS: Of 141 adult decedents, 49% made substantial use of the homelessness services system (known users), 27% made occasional use of these services (occasional users), and 24% had no record of use of homelessness services (nonusers). Compared with known users, nonusers and occasional users were less likely to have had a severe mental illness diagnosis or to have received either disability benefits or Medicaid coverage and were more likely to be white. Nonusers and occasional users were also more likely than known users to have died in outlying parts of the city. CONCLUSIONS: More conventional homeless surveys and enumerations miss a substantial portion of the homeless population. Including these "hidden homeless" persons would alter perceptions about the composition of Philadelphia's homeless population, lowering estimates of the incidence of psychiatric disability and increasing estimates of racial diversity.

Characteristics and Likelihood of Ongoing Homelessness Among Unsheltered Veterans.

INTRODUCTION: Unsheltered homelessness is an important phenomenon yet difficult to study due to lack of data. The Veterans Health Administration administers a universal homelessness screener, which identifies housing status for Veterans screening positive for homelessness. METHODS: This study compared unsheltered and sheltered Veterans, assessed differences in rates of ongoing homelessness, and estimated a mixed-effect logistic regression model to examine the relationship between housing status and ongoing homelessness. RESULTS: Eleven percent of Veterans who screened positive for homelessness were unsheltered; 40% of those who rescreened were homeless six months later, compared with less than 20% of sheltered Veterans. Unsheltered Veterans were 2.7 times as likely to experience ongoing homelessness. DISCUSSION: Unsheltered Veterans differ from their sheltered counterparts-they are older, more likely to be male, less likely to have income-and may be good candidates for an intensive housing intervention. Future research will assess clinical characteristics and services utilization among this population.

Homelessness, Unsheltered Status, and Risk Factors for Mortality: Findings From the 100    000 Homes Campaign.

OBJECTIVES: People who live in unsheltered situations, such as the streets, often have poorer health, less access to health care, and an increased risk of premature mortality as compared with their sheltered counterparts. The objectives of this study were to (1) compare the characteristics of people experiencing homelessness who were sleeping primarily in unsheltered situations with those who were accessing homeless shelters and other sheltered situations, (2) identify correlates of unsheltered status, and (3) assess the relationship between unsheltered status and increased risk of mortality. METHODS: Using primary data collected as part of the 100    000 Homes Campaign-a national effort to help communities find homes for vulnerable and chronically homeless Americans-we estimated 2 generalized linear mixed models to understand the correlates of unsheltered status and risk factors for mortality. Independent variables included demographic characteristics; history of homelessness, incarceration, foster care, and treatment for mental illness or substance use; sources of income; and past and present medical conditions. The study sample comprised 25489 people experiencing homelessness who responded to an assessment of their housing and health as part of the 100    000 Homes Campaign from 2008 to 2014. RESULTS: In the full model, the following characteristics were associated with unsheltered status: being a veteran (adjusted odds ratio [aOR] = 1.10); having 5 years), incarceration (aOR = 1.32), or substance use (aOR = 1.10 for ever abusing drugs or alcohol, aOR = 1.13 for ever using intravenous drugs, aOR = 1.98 for drinking alcohol every day for past month). Being unsheltered (aOR = 1.12), being female (aOR = 1.22), or receiving entitlements (aOR = 1.63) increased respondents' odds of having risk factors for mortality. CONCLUSIONS: These findings highlight the need to assertively reach out to vulnerable populations and provide interventions to assist them during their transition-for example, as they exit incarceration or age out of foster care. Such a response could prevent unsheltered homelessness and thereby address increased mortality risk. Connecting people with resources to increase their access to employment, benefits, and other sources of income is especially important.

Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening.

OBJECTIVE: This study examined veterans' responses to the Veterans Health Administration's (VHA's) universal screen for homelessness and risk of homelessness during the first 12 months of implementation. METHODS: We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen. RESULTS: More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability. CONCLUSION: To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.

Homeless Veterans Eligible for Medicaid Under the Affordable Care Act.

OBJECTIVE: Among homeless veterans and those at risk of homelessness currently enrolled in Veterans Affairs (VA) health care, this study examined the proportion likely to become eligible for Medicaid in 2014 and their health needs. METHODS: A total of 114,497 homeless and at-risk veterans were categorized into three groups: currently covered by Medicaid, likely to become eligible for Medicaid, and not likely. RESULTS: Seventy-eight percent of the sample was determined to be likely to become eligible for Medicaid in states that expand Medicaid. Compared with veterans not likely to become eligible for Medicaid, those likely to become eligible were less likely to have general medical and psychiatric conditions and to have a VA service-connected disability but more likely to have substance use disorders. CONCLUSIONS: Programs serving homeless and at-risk veterans should anticipate the potential interplay between VA health care and the expansion of Medicaid in states that implement the expansion.

Testing Alternative Definitions of Chronic Homelessness.

OBJECTIVE: This study examined the potential impact of a proposed change to the official federal definition of chronic homelessness. METHODS: Using administrative data from the emergency shelters in a large U.S. city, this study estimated the number of persons identified as chronically homeless under the current definition of chronic homelessness, a proposed new federal definition, and two alternative definitions and examined shelter utilization for each group. RESULTS: Fewer than half as many people were considered chronically homeless under the proposed new federal definition compared with the current definition. Persons considered chronically homeless by the proposed new definition and, to a lesser extent, by the two alternative definitions, made heavier use of shelter compared with persons who met the current definition. CONCLUSIONS: A proposed new and two alternative definitions of chronic homelessness are better suited than the existing federal definition for identifying persons with the most protracted experiences of homelessness.

Development and validation of an instrument to assess imminent risk of homelessness among veterans.

OBJECTIVES: Veterans are overrepresented within the homeless population compared with their non-veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among veterans accessing VA health care. METHODS: The study team developed initial assessment items, conducted cognitive interviews with veterans experiencing homelessness, refined pilot items based on veterans' and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk. RESULTS: One-third of veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not. CONCLUSION: This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for veterans who are experiencing or are at risk for homelessness.

Validation of self-reported veteran status among two sheltered homeless populations.

OBJECTIVES: We assessed the accuracy of self-reported veteran status among sheltered homeless adults to assess the reliability of using self-report to determine the number of veterans in homeless populations and examine whether there are demographic correlates to inaccurate reporting of veteran status. METHODS: Records on 5,860 sheltered adults from Columbus, Ohio, and 16,346 sheltered adults from New York City (NYC) were matched with U.S. Department of Veterans Affairs (VA) records. We analyzed the agreement between veteran self-reporting and official records using descriptive measures, diagnostic tests, and logistic regression. RESULTS: The degree of concordance was moderate. Using VA records rather than self-report data to determine veteran status increased homeless veteran prevalence rates by 27% in Columbus and 39% in NYC. Veterans with discordant veteran status (i.e., false positive or false negative) showed lower levels of services use in the VA (both cities) and in the municipal shelter system (NYC only). Younger veterans and women were at higher risk of not being identified as veterans. CONCLUSION: Administrative records can help to more accurately identify homeless veterans and to connect them to available services and benefits.