SDOH Screening Questions Accurately Predict Future Homelessness

Researchers may have uncovered two new SDOH screening questions to ask in the emergency department, with the questions accurately predicting future homelessness, according to new data in JAMA Network Open.

Particularly, the study found that those responding to social determinants of health screening that they thought they may be homeless in the next two months had a higher likelihood of that homelessness coming to fruition.

Being able to effectively screen for and predict future homelessness gives healthcare providers and their community health partners the tools they need for early intervention, preventing serious social determinants of health problems down the road.

Social determinants of health screenings are becoming more common in healthcare, as clinicians across the care continuum issue the surveys to patients to better understand the social factors that may influence health. Using social determinants of health screenings, healthcare providers can refer patients to social services set up to mitigate those risk factors.

An SDOH screening question about food security, for example, may prompt a referral to a local food pantry or nutrition program.

This latest study is one of the earliest looks into how an SDOH screening could detect risk for homelessness, not current homelessness. The researchers asked 1,919 patients visiting an ED in New York City two questions to determine their risk for homelessness:

• “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?” with responses of “yes” or “no”
• “How likely do you think it would be that you would have to use a homeless shelter in the next 6 months?” with four response options ranging from “very unlikely” to “very likely” 

Researchers then followed up with patients at two-, six-, and 12-month intervals to determine whether the patient had, in fact, fallen into homelessness. By the study’s end, 2.3 percent, 3.4 percent, and 5 percent of patients had entered a shelter, respectively.

Overall, folks who had answered yes to either of the screening questions, but especially the first one, were significantly more likely to eventually enter a shelter.

For example, at the two-month follow-up, the researchers found that 6.5 percent of those who were worried about stable housing had entered a shelter; only 1 percent of those who were not worried also fell into homelessness.

Importantly, the SDOH screening questions were both sensitive and specific, meaning that they could pretty effectively identify folks who would become homeless and sort out those who would not. Sensitivity of the screening questions ranged from 0.27 to 0.69, and specificity from 0.76 to 0.97.

The researchers could not recommend which screening question was better, explaining healthcare organizations should carefully review their resources to determine the best fit.

“Ultimately, preference for which question or questions should be used will vary based on goals of screening, likelihood that individuals administering the screening will do so with fidelity, and interventions or services that a positive screen may trigger,” the research team wrote.

For example, the first question asking whether a patient was worried about housing stability was more sensitive, but it had a higher risk for false negatives; a patient might say they are worried but not end up homeless. A healthcare organization may choose to ask this question during screening if they lean on low-cost interventions, like a consultation with a social worker.

But if a healthcare organization uses more costly housing interventions, like housing vouchers, they may want to avoid false negatives. The second question, asking respondents to rate their risk of entering a shelter, might be more judicious.

Healthcare organizations may also consider the provider workflows when implementing SDOH screening, the study authors noted.

“Although more work is needed to bring such programs to scale, the primary task for EDs may be identifying patients at increased risk and providing effective referrals to services,” they concluded.