Faculty Bibliography

OBJECTIVE:To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes. DATA SOURCES/METHODS:Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database. STUDY DESIGN/METHODS:Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires. DATA COLLECTION/EXTRACTION METHODS/METHODS:Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching. PRINCIPAL FINDINGS/RESULTS:Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry. CONCLUSIONS:Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.

Importance:There has been recent media attention on the risk of excess mortality among homeless individuals during the COVID-19 pandemic, yet data on these deaths are limited. Objectives:To quantify and describe deaths among people experiencing homelessness in San Francisco during the COVID-19 pandemic and to compare the characteristics of these deaths with those in prior years. Design, Setting, and Participants:A cross-sectional study tracking mortality among people experiencing homelessness from 2016 to 2021 in San Francisco, California. All deceased individuals who were homeless in San Francisco at the time of death and whose deaths were processed by the San Francisco Office of the Chief Medical Examiner were included. Data analysis was performed from August to October 2021. Exposure:Homelessness, based on homeless living status in an administrative database. Main Outcomes and Measures:Descriptive statistics were used to understand annual trends in demographic characteristics, cause and manner of death (based on autopsy), substances present in toxicology reports, geographic distribution of deaths, and use of health and social services prior to death. Total estimated numbers of people experiencing homelessness in San Francisco were assessed through semiannual point-in-time counts. The 2021 point-in-time count was postponed owing to the COVID-19 pandemic. Results:In San Francisco, there were 331 deaths among people experiencing homelessness in the first year of the COVID-19 pandemic (from March 17, 2020, to March 16, 2021). This number was more than double any number in previous years (eg, 128 deaths in 2016, 128 deaths in 2017, 135 deaths in 2018, and 147 deaths in 2019). Most individuals who died were male (268 of 331 [81%]). Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury. COVID-19 was not listed as the primary cause of any deaths. The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic). Fewer decedents had contacts with health services in the year prior to their death during the pandemic than in prior years (13% used substance use disorder services compared with 20% in 2019). Conclusions and Relevance:In this cross-sectional study, the number of deaths among people experiencing homelessness in San Francisco increased markedly during the first year of the COVID-19 pandemic. These findings may guide future interventions to reduce mortality among individuals experiencing homelessness.

Objectives/UNASSIGNED:We aim to assess the influence of COVID-19 on the social needs of emergency department (ED) patients, and assess patients' access to social services. Methods/UNASSIGNED:We conducted a cross-sectional survey of 175 purposively sampled adult ED patients. Results/UNASSIGNED:Approximately half of participants stated that COVID-19 negatively impacted their social needs with statistically significant differences observed for race, ethnicity, and insurance status. Many participants did not know of available social services, and a majority welcomed assistance from the ED. Conclusion/UNASSIGNED:This study suggests that unmet social needs have risen because of COVID-19, and EDs may be positioned to identify and assist affected patients.

BACKGROUND:The COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a "Big Events" approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs. METHODS:Between July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic. RESULTS:Among 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic. CONCLUSION:These findings build on the "Big Events" approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.

BACKGROUND/UNASSIGNED:Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. METHODS/UNASSIGNED:As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. RESULTS/UNASSIGNED:Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. CONCLUSIONS/UNASSIGNED:The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

INTRODUCTION/BACKGROUND:Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients. METHODS:We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status. RESULTS:One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models. CONCLUSION/CONCLUSIONS:The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.