Homeless patients at risk for higher ED use before and after shelter stays

Emergency Department
A new study shows that individuals using homeless shelters showed a spike in emergency department utilization before they entered the shelter and after they exited. (Studio 642/Getty Images))

A new study underscores the potential for effective collaboration between hospitals and services for the homeless.

Published in the September issue of Health Affairs, the study looked at administrative records from New York City’s municipal shelter system and an all-payer claims database of hospital visits in New York City to track emergency department (ED) use among first-time users of shelter facilities.

Between 2009 and 2015, 39.3% of first-time shelter users either visited an ED or were hospitalized in the year before entering a shelter. In the year after they left the shelter, 43.3% either visited the ED or were hospitalized.


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While previous studies have looked at hospital use among homeless people while they reside in shelters, few have looked at their use before entering the shelter. The research team had difficulty finding any studies at all looking at the time period after people leave the shelter, according to study author Kelly Doran, M.D., assistant professor in the departments of emergency medicine and population health at New York University School of Medicine.

“We obviously know a lot about how on average people who are homeless tend to use the hospital more than other people, and also about how a certain subset of people who are homeless are quite frequent users. But this study is unique in looking at the before and after time period,” Doran told FierceHealthcare.

The study’s results can’t shed light on exactly why these spikes in usage exist, but they do suggest a policy opening that hospitals and government programs could exploit.

“The majority of people entering homeless shelters are not coming in via hospitals, but what we found does demonstrate a connection and that hospitals, including emergency departments, could probably be doing more to help, especially because homelessness is such a crisis in so many places,” Doran said.

That connection may provide an opening for hospitals to coordinate with government and community organizations to improve efforts around screening for housing insecurity issues, which the Robert Wood Johnson Foundation recently identified as a top priority for healthcare systems.

“When you look at the literature about what social problems emergency department patients face, housing instability and homelessness is always at the top,” Doran said.

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Interest in improving health outcomes by tackling housing insecurity issues has led some hospitals to pursue larger-scale initiatives such as permanent supportive housing, but Doran suggests less expensive interventions such as referring patients to homelessness-prevention services could be a better fit for populations that aren’t necessarily experiencing a chronic need.

In more general terms, she said despite the increasing focus on social determinants of health, research that helps nail down evidence-based practices still lags.

“One of the things the study shows is that it requires real collaboration within a community among systems, because all communities are different—New York is very different from Los Angeles and obviously very different from a more rural area,” she said.