"It Wasn't Just One Thing": A Qualitative Study of Newly Homeless Emergency Department Patients

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.

Patient views on emergency department screening and interventions related to housing

Objectives Emergency departments (EDs) serve as a health care "safety net" and may be uniquely suited to screening for and addressing patients' unmet social needs. We aimed to better understand patient perspectives on ED-based screening and interventions related to housing instability, as a step toward improving future efforts. Methods We present findings from a qualitative study using in-depth, one-on-one interviews with ED patients who had become homeless in the past 6 months. Qualitative interviewees were asked their thoughts on ED staff asking about and helping to address homelessness and housing issues. Interviews were professionally transcribed verbatim. Multiple coders identified interview text segments focused on ED-based housing screening and intervention, which were then independently analyzed thematically and discussed to reach consensus. Researchers also categorized each participant's overall opinion on ED housing screening and interventions as positive, neutral, or negative. Results Qualitative interviews were conducted with 31 patients. Four themes related to ED-based housing screening and interventions emerged: (1) patients generally welcome ED staff/providers asking about and assisting with their housing situation, with caveats around privacy and respect; (2) ED conversations about housing have potential benefits beyond addressing unmet housing needs; (3) patients may not consider the ED as a site to obtain help with housing; (4) patients' experiences navigating existing housing services can inform best approaches for the ED. Most participants expressed overall positive views of ED staff/providers asking patients about their housing situation. Conclusions Study participants generally felt positively about screening and interventions for housing in the ED. Insights from this study can inform future ED-based housing instability screening and interventions.

Social relationships, homelessness, and substance use among emergency department patients

BACKGROUND

Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness.

METHODS

As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions.

RESULTS

Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described.

CONCLUSIONS

The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.