How SDOH screening can provide population-level health insights

A universal housing security and social determinants of health (SDOH) screening process in the emergency department is providing key insights into the social supports necessary to cut down on ED utilization, researchers from Vanderbilt University Medical Center wrote in JAMA Network Open.

Overall, 5 percent of patients presenting in VUMC’s emergency department screened positive for housing insecurity between January and May 2023, and they mostly needed mental and behavioral health help. Patients screening positive for housing insecurity were also more likely to have limited or no insurance coverage, the researchers said.

These findings not only illustrate the feasibility of a universal SDOH screening that focuses on housing status but also outline what kinds of healthcare and social support individuals need to cut down on ED visits. Individuals experiencing housing insecurity have higher rates of ED utilization, but focusing on the health issues bringing them into healthcare facilities and other trends could cut down on those numbers.

That’s in the context of growing ED overutilization and overcrowding.

“Unstable housing and homelessness can exacerbate adverse and inequitable health outcomes,” the researchers explained in the study’s introduction. “Individuals experiencing homelessness are at greater risk of chronic diseases, infectious diseases, injury, and disability, leading to increased acute hospital visits and emergency department (ED) morbidity and mortality.”

Now, after implementing the Homelessness Screening Clinical Reminder (HSCR) into ED registration and triage, VUMC has better insights into the prevalence of homelessness in their ED and the types of healthcare concerns arising among this population.

The HSCR asks two questions:

1. In the past 2 months, have you been living in stable housing that you own, rent, or stay in as part of a household? (Negative response indicates current unhoused status.)
2. Are you worried or concerned that in the next 2 months you may not have stable housing that you own, rent, or stay in as part of a household? (Positive response indicates risk of future homelessness.)

Overall, 23,795 patients visited the VUMC during the HSCR’s initial rollout and completed the screening. Of those patients, around 5 percent screened positive for housing insecurity, with the median age being 46 years. Seven in 10 patients screening positive for housing insecurity identified as men, the researchers said.

Notably, mental and behavioral health concerns were chief among housing insecure ED patients, with 11 percent presenting with suicidality and 10 percent presenting with intoxication. This was far more common than in the population screening negative for housing insecurity (1 percent and 2 percent, respectively).

“Overall, these findings point to a need for more comprehensive psychiatric care, including suicide prevention and support for treating substance use disorders for patients experiencing homelessness as well as additional community support and bolstered coordination between EDs and mental health care facilities,” the researchers explained. “Finally, continued efforts should be made to maintain resources overnight and bring mental health care directly to the street.”

Moreover, the researchers observed high rates of uninsurance among the housing insecure group, with a third of them reporting no health payer coverage. That compares to 10 percent of the housing secure group reporting the same.

People screening positive for housing insecurity were also more likely to have multiple visits during the study period and to have visits between 8 p.m. and 6 a.m.

“This finding supports data suggesting that those experiencing homelessness are more likely to use the ED with greater frequency but, most importantly, points to a small proportion of individuals experiencing homelessness constituting a considerable proportion of visits,” the researchers said. “If additional resources can be directed to this relatively small group of individuals, the impact could be significant.”

The universal SDOH screening, plus the screening findings, gave VUMC researchers and staff members a lot to work from, the study indicated.

For one thing, the screenings helped loop in staff members who could help address housing insecurity and SDOH. For 78 percent of ED visits with positive housing insecurity results, the ED team called in a member of the social work team to assess the patient.

The breakdown of housing insecurity by patient demographics also provided key insights. For example, patients who screened positive for housing insecurity were more likely to arrive at the ED via ambulance or public transportation, indicating personal transportation barriers. This could limit patient access to other types of care, like primary care, and lead to acute ED needs.

The findings about no or limited insurance coverage among housing insecure patients can also indicate poor access to primary and preventive care.

Fundamentally, these findings underscore the need for universal SDOH screening within the ED, the researchers said. In doing so, hospitals and health systems can better tailor strategic decisions.

“Understanding details of the previously underrecognized population experiencing homelessness will enable our center to continue directing resources to improve health and social conditions that lead to health inequities,” the researchers concluded. “Specifically, we are using these data to develop a multidisciplinary homeless health care team that includes in-hospital and street medical care for people experiencing homelessness and housing insecurity.”