Predictors of repeated emergency department visits among persons treated for addiction

Factors associated with presentation to the emergency department during an intensive post-discharge intervention in patients with substance use disorders

BACKGROUND

Early identification of patients with substance use disorders (SUDs) with a higher risk of emergency department (ED) presentations after being discharged can be useful. We performed a chart review of patients from the Intensive Recovery Discharge Team (IRDT) program, which provides two weeks of outpatient support for patients with SUDs discharged from a mental health hospital.

METHOD

Demographic, service utilization, and clinical data from 716 patients enrolled in IRDT from February 2021-February 2023 were extracted from electronic health records. Receiver operating characteristic (ROC) analysis was performed to identify risk factors associated with increased ED presentations during the two weeks of IRDT follow-up with five-fold cross validation.

RESULTS

In two years, 10.7% of IRDT patients presented to the ED during the 2 weeks of follow-up. Having been enrolled in IRDT more than once, not having opioid use disorder (OUD), and self-identifying as male was associated with ED presentations, where an average of 20.1% of patients with all three risk factors presented to the ED. The presence of comorbid mental disorders did not emerge as a significant predictor.

DISCUSSION

Our results suggest that patients who had previous inpatient admissions, a SUD other than OUD, and/or self-identify as male have a higher risk of presenting to the ED post-discharge and may benefit from more intensive follow-up. Larger studies involving multiple sites are required to validate the generalizability of our findings. Findings from our study can be used to guide future studies examining post-discharge programs in patients with SUDs with and without comorbid mental disorders.

Characteristics of Patients Presenting at an Emergency Department for a Heroin Overdose vs Detoxification

Purpose

This study compares substance use, treatment histories, and sociodemographic characteristics of patients presenting to an emergency department (ED) following a heroin overdose or seeking detoxification services for heroin and examines risk factors for a subsequent return to the ED for a substance-related problem.

Methods

A convenience sample of patients presenting for an overdose or detoxification at an urban teaching ED was recruited for this study. During their ED visit, patients were interviewed regarding demographics, substance use experiences, and treatment history. Subsequently, a review of patient records for past and subsequent ED use was performed.

Results

Patients requesting detox and those with an overdose were similar in terms of prior treatment. Both groups had similar extensive polysubstance histories. As a group, however, patients presenting for detox were more likely to report use of each of three substances (benzodiazepines, opioid pain medications, and heroin) more than three times per week, compared to those presenting for overdose. Detox patients had higher scores on the 3-item Alcohol Use Disorder Identification Test-C and the drug problems scale compared to overdose patients. Overall, 28% of the patients returned to the ED within 90 days for a drug-related issue, including 8% that returned for an overdose. Factors predictive of a return ED visit included ED visits for substance use in the previous year and recent frequent heroin use.

Conclusion

Patients requesting detox were similar in most domains to those presenting following an overdose. Notably, overdose patients were less likely to use heroin more than three times per week compared to detox patients. Both groups were equally likely to return for an SUD reason within 3-months, however for both groups, previous ED visits and recent frequent heroin use predicted a return visit.

Acute care utilization and its associated determinants among patients with substance-related disorders: A worldwide systematic review and meta-analysis

INTRODUCTION

Identifying determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRDs) can improve health services to address unmet health needs.

AIM

The present study aimed to identify the prevalence rates of ED use and hospitalization, and their associated determinants among patients with SRDs.

METHODS

Studies in English published from January 1, 1995, to December 1, 2022, were searched on PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies.

RESULTS

The pooled prevalence rates of ED use and hospitalization among patients with SRDs were 36% and 41%, respectively. Patients with SRDs who were the most at risk of being both ED users and hospitalized were those (i) having medical insurance, (ii) having other drug and alcohol use disorders, (iii) having mental health disorders, and (iv) having chronic physical illnesses. A lower level of education increased the risk of ED use only.

DISCUSSION

To decrease ED use and hospitalization, more comprehensive services may be offered to these vulnerable patients with diversified needs.

IMPLICATIONS FOR PRACTICE

Chronic care integrating outreach interventions could be more provided for patients with SRDs after discharge from acute care units or hospitals.

Predictors of Emergency Department Use for Suicidal Behaviors among Patients with Substance-Related Disorders

OBJECTIVE

This study aimed to identify predictors of emergency department (ED) use for suicide ideation or suicide attempt compared with other reasons among 14,158 patients with substance-related disorders (SRD) in Quebec (Canada).

METHODS

Longitudinal data on clinical, sociodemographic, and service use variables for patients who used addiction treatment centers in 2012-13 were extracted from Quebec administrative databases. A multinomial logistic regression was produced, comparing predictors of suicide ideation or attempts to other reasons for ED use in 2015-16.

RESULTS

Patients using ED for both suicide ideation and attempt were more likely to have bipolar or personality disorders, problems related to the social environment, 4+ previous yearly outpatient consultations with their usual psychiatrist, high prior ED use, and dropout from SRD programs in addiction treatment centers in the previous 7 years, compared with those using ED for other reasons. Patients with alcohol- or drug-related disorders other than cannabis and living in the least materially deprived areas, urban territories, and university healthcare regions made more suicide attempts than those using ED for other reasons. Patients with common mental disorders, 1-3 previous yearly outpatient consultations with their usual psychiatrist, one previous treatment episode in addiction treatment centers, and those using at least one SRD program experienced more suicide ideation than patients using ED for other reasons.

CONCLUSION

Clinical variables most strongly predicted suicidal behaviors, whereas completion of SRD programs may help to reduce them. SRD services and outreach strategies should be reinforced, particularly for patients with complex issues living in more advantaged urban areas. HIGHLIGHTSOver 10% of ED visits were for suicidal behaviors among patients with SRD.ED use for suicidal behaviors was mainly associated with clinical variables.Addiction treatment centers may help reduce ED use for suicidal behaviors.

Predictors of no, low and frequent emergency department use for any medical reason among patients with cannabis-related disorders attending Quebec (Canada) addiction treatment centres

INTRODUCTION

Patients with substance-related disorders and mental disorders (MD) contribute substantially to emergency department (ED) overcrowding. Few studies have identified predictors of ED use integrating service use correlates, particularly among patients with cannabis-related disorders (CRD). This study compared predictors of low (1-2 visits/year) or frequent (3+ visits/year) ED use with no ED use for a cohort of 9836 patients with CRD registered at Quebec (Canada) addiction treatment centres in 2012-2013.

METHODS

This longitudinal study used multinomial logistic regression to evaluate clinical, sociodemographic and service use variables from various databases as predictors of the frequency of ED use for any medical reason in 2015-2016 among patients with CRD.

RESULTS

Compared to non-ED users with CRD, frequent ED users included more women, rural residents, patients with serious MD and chronic CRD, dropouts from programs in addiction treatment centres and with less continuity of physician care. Compared with non-users, low ED users had more common MD and there more workers than students.

DISCUSSION AND CONCLUSIONS

Multimorbidity, including MD, chronic physical illnesses and other substance-related disorders than CRD, predicted more ED use and explained frequent use of outpatient services and prior specialised acute care, as did being 12-29 years, after controlling for all other covariates. Better continuity of physician care and reinforcement of programs like assertive community or integrated treatment, and chronic primary care models may protect against frequent ED use. Strategies like screening, brief intervention and treatment referral, including motivational therapy for preventing treatment dropout may also be expanded to decrease ED use.

Profiles of individuals with cannabis-related disorders

Background: Profiles of individuals with cannabis-related disorders (CRD) in specialized addiction treatment centers serving high-need patients have not been identified. This longitudinal study developed a typology for 9,836 individuals with CRD attending Quebec (Canada) addiction treatment centers in 2012-2013. Methods: Data on sociodemographic, clinical and service use variables were extracted from several databases for the years 1996-1997 to 2014-2015. Individual profiles were produced using Latent Class Analysis and compared predicting health outcomes on emergency department (ED) use, hospitalizations and suicidal behaviors for 2015-2016. Results: Six profiles were identified: 1-Older individuals, many living in couples and working, with moderate health problems, receiving intensive general practitioner (GP) care and high continuity of physician care; 2-Older individuals with chronic CRD, multiple social and health problems, and low health service use (chronic CRD referred to experiencing CRD for several years; social problems related to homelessness, unemployment, having criminal records or living alone); 3-Students with few social and health problems, and low health service use; 4-Young adults, many working, with few health problems, least health service use and continuity of physician care; 5-Youth, many working but some criminal offenders, with 1 or 2 years of CRD, few health problems and high addiction treatment center use; and 6-Older individuals with chronic CRD and multiple social and health problems, high health service use and continuity of physician care. Profiles 6 and 2 had the worst health outcomes. Conclusions: For Profiles 2 to 5, outreach and motivational services should be prioritized, integrated health and criminal justice services for profile 5 and, for Profiles 2 and 6, assertive community treatments. Screening, brief intervention and referrals to addiction treatment centers may also be encouraged for individuals with CRD, particularly those in Profile 2. This cohort had high social and health needs relative to services received, suggesting continued need for care.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Non-disclosure of drug use in outpatient health care settings: Findings from a prospective cohort study in Vancouver, Canada

BACKGROUND

Illicit drug use is associated with severe health-related harms, yet people who use drugs (PWUD) face substantial barriers to healthcare. We sought to identify factors associated with disclosure of drug use to a healthcare provider and describe differences in self-reported quality of care received based on disclosure status.

METHODS

A client-reported experience questionnaire on healthcare access and quality, adapted from the World Health Organization Survey on Health and Health System Responsiveness, was administered within two ongoing prospective cohort studies of PWUD in Vancouver, Canada. Respondents not currently receiving addiction treatment were asked about experience of care and drug use disclosure to their most commonly accessed outpatient healthcare provider in the past 6 months. We used an adjusted logistic regression model to identify client characteristics associated with disclosure.

RESULTS

From a total of 261 respondents (34.1% female), less than half (n = 125, 47.8%) reported disclosing drug use to their healthcare provider. Indigenous participants were less likely to disclose compared to non-Indigenous participants (adjusted OR: 0.55, 95% confidence interval: 0.30, 0.97). Disclosure was associated with lower self-reported quality of care (overall rating: disclosed 8.2 vs. did not disclose 8.8, p = 0.04).

CONCLUSIONS

In a sample of PWUD accessing outpatient healthcare services, we observed low rates of drug use disclosure, particularly for Indigenous respondents, and reduced quality of care for those who disclosed. These findings highlight the need for culturally safe and non-stigmatizing care to address pervasive stereotyping in the healthcare system and improved screening for substance use disorder in outpatient healthcare services.

Homeless people under the influence of alcohol admitted to hospital emergency departments in Poland

Aim:

To assess the incidence of diagnoses related to alcohol use in the population of homeless people admitted to hospital emergency departments (EDs).

Material and method:

Data were analysed from three hospitals concerning stays of homeless people in three EDs in Bydgoszcz, Poland, in 2013–2015; 3133 stays were identified. The data were compiled using Microsoft Excel and Statistica 10 statistical software.

Results:

At the time of admission to EDs, 31% of homeless people were considered to be under the influence of alcohol. Diagnoses related to alcohol use accounted for 25% of all diagnoses. The average blood alcohol concentration in the patients was 2.97 per mille. The average blood alcohol concentration in the group of men was significantly higher than that in the group of women (p = 0.015). The average length of stay in the ED of patients under the influence of alcohol was significantly longer (p < 0.0001) than among sober patients.

Conclusions:

Homeless people under the influence of alcohol account for a third of the population of homeless patients admitted to hospital emergency departments, while alcohol-related ICD-10 diagnoses account for a fourth of all diagnoses in these patients. Homeless patients under the influence of alcohol stay longer in hospital emergency departments than do sober homeless people, which may translate into more frequent acts of aggression towards medical personnel. In Poland there are no systemic ED-level solutions as regards dealing with homeless patients for whom alcohol dependence is in many cases a reality.

Variables associated with low, moderate and high emergency department use among patients with substance-related disorders

AIMS

This study identified factors associated with frequency of emergency department (ED) use for medical reasons among patients with substance-related disorders (SRD) in Quebec (Canada) for 2014-15.

METHODS

Participants (n = 4731) were categorized as: 1) low (1 visit/year), 2) moderate (2 visits/year), and 3) high (3+ visits/year) ED users. Independent variables included predisposing, enabling and needs factors based on the Andersen Behavioral Model. Multinomial logistic regression identified associated variables.

RESULTS

Factors positively associated with moderate and high ED use included adjustment disorders, suicidal behavior, alcohol-induced disorders, less urgent to non-urgent illness acuity, referral to local health community services centers (LHCSC) at discharge, and living in a materially deprived area. Factors positively associated with high ED use only included anxiety disorders, alcohol use disorders, drug use disorders, chronic physical illness, subacute problems, prior ED use for MD and/or SRD, prior LHCSC medical interventions, physician consultation within one month after discharge, living in very deprived or middle-class areas, and, negatively, being hospitalized for medical reasons in second ED visit. Moderate ED use only was negatively associated with alcohol intoxication and being referred to a GP at ED discharge.

CONCLUSIONS

Compared to low ED users, most high users with SRD were men presenting more complex and severe conditions. They visited ED mainly for subacute or non-urgent problems. Compared to low ED users, most moderate users had alcohol-induced disorders, less alcohol intoxication, and acute common MD. They visited ED mainly for non-urgent care. Diverse strategies should be implemented to reduce ED visits, targeting each group.

Mental and behavioral disorders in the population of homeless patients admitted to hospital emergency departments

The aim of the study is to identify the most common mental and behavioral disorders diagnosed in homeless patients admitted to hospital emergency departments and to identify performed medical procedures including diagnostic and therapeutic measures in this range.

Material and Method:Data from information systems of three hospitals concerning stays of homeless people in ED in Bydgoszcz in 2013-2015 were analyzed. As any as 3133 stays were identified. The data was compiled using the Microsoft Excel spreadsheet and Statistica 10 statistical software package.

Results: Diagnoses in the category of mental disorders and behavioral disorders constituted 23.3% of diagnoses made in the studied population, of which two thirds were psychiatric disorders and behavioral disorders caused by alcohol use. Specific personality disorders (5.84%), schizophrenia (3.82%), and mild mental retardation (2.24%) were diagnosed in patients. One tenth of all the ICD-9 procedures performed were the procedures of the category 94- Procedures related to mental condition

Conclusions: Mental and behavioral disorders are one of the main reasons for admission of homeless people to hospital emergency departments. Most diseases is diagnosed in facilities where psychiatric consultation is possible, as well as where the number of procedures related to mental condition performed is the highest. Homeless patients suffering from mental and behavioral disorders are rarely admitted to hospital wards for hospitalization. Psychiatric care for homeless patients admitted to emergency departments is an ad hoc intervention and depends on the availability of a psychiatrist. Providing homeless patients with access to a psychiatric diagnosis at ED level would affect the quality of psychiatric care and would contribute to the improvement of mental health of homeless people.

Developing a patient-reported experience questionnaire with and for people who use drugs: A community engagement process in Vancouver's Downtown Eastside

People who use drugs (PWUD) frequently have complex health care needs, yet face multiple barriers to accessing services. Involving PWUD in health service design and evaluation can enhance the quality of data collected and ensure policy and practice improvements reflect the expressed needs of the population. However, PWUD remain largely excluded from the evaluation of health services that directly affect their lives, including development of patient-reported experience measures (PREMS) that have gained prominence in health services research and clinical practice. Detailed descriptions of PWUD participation in survey design are notably absent in the literature. In this commentary, we present a case that demonstrates how PWUD can contribute meaningfully to the development of questionnaires that assess patient-reported health care experiences. We describe the development, implementation and outcomes of a process to engage local drug user organizations in the evaluation of a redesign and reorientation of health service delivery in the Downtown Eastside (DTES) neighborhood of Vancouver, Canada. Through this process, participants contributed critical elements to the design of a patient-reported experience measure, including: (1) identifying unmet service needs in the neighborhood; (2) identifying local barriers and facilitators to care; (3) formulating questions on cultural safety; and (4) improving structure, language and clarity of the questionnaire. We highlight lessons learned from the process, reflecting on the strengths, challenges and ethical considerations associated with community-based approaches to questionnaire development. The workshop model presented here illustrates one flexible and promising approach to enabling meaningful participation of PWUD in questionnaire development.

Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons

Background

Understanding why people repeatedly attend Emergency Departments (EDs) for alcohol-related reasons is an important prerequisite to identifying ways of reducing any unnecessary demands on hospital resources. We use Andersen’s Behavioural Model of Health Services Use to explore factors that contributed to repeat ED attendances.

Methods

Qualitative interviews were conducted with 30 people who repeatedly attended EDs for alcohol-related reasons (≥10 attendances in the past 12 months). We recruited participants from 6 EDs in London, United Kingdom. Data on socio-demographic characteristics, substance use, contact with specialist addiction and other health services, most recent ED attendance, and previous ED attendances were analysed.

Results

Participants reported long-standing health problems, almost all were unemployed, and many had limited education and unstable housing. Most held positive health beliefs about EDs, despite some negative experiences. They reported limited community resources: poor social support, inaccessible primary care services, dislike or lack of information about specialist addiction services, and difficulties travelling to services. In contrast, EDs offered immediate, sympathetic care and free transport by ambulance. Participants’ perceived need for care was high, with physical injury and pain being the main reasons for ED attendance.

Conclusions

Push’ and ‘pull’ factors contributed to repeated ED use. ‘Push’ factors included individual-level problems and wider community service failings. ‘Pull’ factors included positive experiences of, and beliefs about, ED care. Community services need to better engage and support people with complex drinking problems, whilst ED staff can be more effective in referring patients to community-based services.

Survival of patients with alcohol use disorders discharged from an emergency department: a population-based cohort study

OBJECTIVES

The aim was to study the cause-specific mortality of users of the emergency department (ED) who received a diagnosis of alcohol use disorder (AUD) in comparison with mortality of other users of the department.

DESIGN

A population-based prospective cohort study.

PARTICIPANTS

All patients aged 18 years and above who were subsequently discharged home from the ED during the years 2002-2008. A total of 107,237 patients were followed by record linkage to a nationwide cause-of-death registry: 1210 patients with AUD as the main discharge diagnosis and 106,027 patients in the comparison group. HR and 95% CIs were calculated.

SETTING

ED at Landspitali-the National University Hospital of Iceland, Reykjavik, Iceland. The hospital offers tertiary care and is the number one trauma centre and community hospital for the greater Reykjavik area. According to the population registry, 78% of the inhabitants of the area attended the ED during the study period.

RESULTS

72 patients died in the AUD group and 4807 in the comparison group. The adjusted HR for all causes of death was 1.91 (95% CI 1.51 to 2.42). The HR for AUDs was 47.68 (95% CI 11.56 to 196.59) while for alcohol liver disease the HR was 19.06 (95% CI 6.07 to 59.87). The HR was also elevated for diseases of the circulatory system: HR 2.52 (95% CI 1.73 to 3.68); accidental poisoning: HR=13.64, (95% CI 3.98 to 46.73); suicide: HR=2.72 (95% CI 1.08 to 6.83); and event of undetermined intent: HR=10.89 (95% CI 4.53 to 26.16).

CONCLUSIONS

AUD as the discharge diagnosis at the ED, among patients who were not admitted to a hospital ward but discharged home, predicts increased mortality. As the results conclusively show the vulnerability of these patients, one can question whether their needs are adequately met at the ED.

Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study

STUDY OBJECTIVE

We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.

METHODS

We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.

RESULTS

Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.

CONCLUSION

Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.

Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada

Aims

Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision.

Methods

EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada.

Findings

The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges.

Conclusions

Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.

Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users

We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.