Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department

Introduction: Our objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED. Methods: We surveyed patients in an urban, safety-net ED from June-August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents. Results: Of those surveyed, 35% (95% confidence interval [CI], 31-38) identified as homeless and 28% (95% CI, 25-31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29-64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24-64) with unstable housing presenting over the next eight hours. Conclusion: The ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed.