Faculty Bibliography

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.

INTRODUCTION/BACKGROUND:Healthcare systems are increasingly interested in identifying patients' housing-related risks, but minimal information exists to inform screening question selection. The primary study aim is to evaluate discordance among 5 housing-related screening questions used in health care. METHODS:This was a cross-sectional multisite survey of social risks used in a convenience sample of adults seeking care for themselves or their child at 7 primary care clinics and 4 emergency departments across 9 states (2018-2019). Housing-related risks were measured using 2 questions from the Accountable Health Communities screening tool (current/anticipated housing instability, current housing quality problems) and 3 from the Children's HealthWatch recommended housing instability screening measures (prior 12-month: rent/mortgage strain, number of moves, current/recent homelessness). The 2-sided Fisher's exact tests analyzed housing-related risks and participant characteristics; logistic regression explored associations with reported health (2019-2020). RESULTS:Of 835 participants, 52% screened positive for ≥1 housing-related risk (n=430). Comparing the tools, 32.8% (n=274) screened discordant: 11.9% (n=99) screened positive by Children's HealthWatch questions but negative by Accountable Health Communities, and 21.0% (n=175) screened positive by the Accountable Health Communities tool but negative by Children's HealthWatch (p<0.001). Worse health was associated with screening positive for current/anticipated housing instability (AOR=0.56, 95% CI=0.32, 0.96) or current/recent homelessness (AOR=0.57, 95% CI=0.34, 0.96). CONCLUSIONS:The 5 housing questions captured different housing-related risks, contributed to different health consequences, and were relevant to different subpopulations. Before implementing housing-related screening initiatives, health systems should understand how specific measures surface distinct housing-related barriers. Measure selection should depend on program goals and intervention resources.

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.

OBJECTIVE:People experiencing homelessness (PEH) have high rates of substance use, and homelessness may be an important driver of health disparities in the opioid overdose epidemic. However, few studies focus on homelessness among the opioid use disorder (OUD) treatment population. We examine national-level trends in substance use treatment admissions among PEH with OUD. METHODS:This study used data from first-time treatment admissions in the United States from the Treatment Episode Data Set: Admissions (TEDS-A) to examine characteristics and trends of adults experiencing homelessness who entered state-licensed substance use treatment programs for OUD from 2013 to 2017. We used chi-squared analyses to examine changes in characteristics of this population over time and logistic regression to assess characteristics associated with receipt of medications for opioid use disorder (MOUD) among PEH. RESULTS:Among all adults with OUD entering specialty treatment from 2013 to 2017, 12.5% reported experiencing homelessness. Compared to individuals not experiencing homelessness, PEH were more likely to be male, inject opioids, use cocaine or methamphetamine, and enter into residential detoxification treatment. PEH were less likely to enter outpatient treatment or receive MOUD. From 2013 to 2017, significant increases occurred in the proportion of PEH who had co-occurring psychiatric problems and used methamphetamines. Over time, treatment type shifted significantly from residential detoxification to outpatient treatment. Receipt of MOUD increased among PEH over time (13.7% to 25.2%), but lagged behind increases among individuals not experiencing homelessness. Among PEH, being older was associated with receiving MOUD, while concurrent methamphetamine use [adjusted odds ratio (AOR) 0.63; 95% CI 0.58, 0.69] and living in the southern United States (AOR 0.27; 95% CI 0.25, 0.30) were associated with not receiving MOUD. DISCUSSION/CONCLUSIONS:The proportion of PEH with OUD who receive medications as part of treatment increased over time, but three quarters of PEH entering treatment still do not receive this highest standard in evidence-based care. The sharp increase observed in concomitant methamphetamine use in this population is concerning and has implications for treatment.

BACKGROUND/UNASSIGNED:: Those with exposure to abuse, homelessness, and both adverse outcomes constitute a high-risk population for substance use. Addressing abuse and homelessness should be a component of preventing drug risk for screening, treatment, and prevention efforts.

BACKGROUND:Worsening socioeconomic conditions in rural America have been fueling increases in chronic disease and poor health. The goal of this study was to identify cost-effective methods of deploying geographically targeted health surveys in rural areas, which often have limited resources. These health surveys were administered in New York's rural Sullivan County, which has some of the poorest health outcomes in the entire state. METHODS:Comparisons were made for response rates, estimated costs, respondent demographics, and prevalence estimates of a brief health survey delivered by mail and phone using address-based sampling, and in-person using convenience sampling at a sub-county level in New York's rural Sullivan County during 2017. RESULTS:Overall response rates were 27.0% by mail, 8.2% by phone, and 71.4% for convenience in-person surveys. Costs to perform phone surveys were substantially higher than mailed or convenience in-person surveys. All modalities had lower proportions of Hispanic respondents compared to Census estimates. Unadjusted and age-adjusted prevalence estimates were similar between mailed and in-person surveys, but not for phone surveys. CONCLUSIONS:These findings are consistent with declining response rates of phone surveys, which obtained an inadequate sample of rural residents. Though in-person surveys had higher response rates, convenience sampling failed to obtain a geographically distributed sample of rural residents. Of modalities tested, mailed surveys provided the best opportunity to perform geographically targeted rural health surveillance.

STUDY OBJECTIVE/OBJECTIVE:Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. METHODS:We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. RESULTS:Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. CONCLUSION/CONCLUSIONS:In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

Health and housing consortia in New York City offer a model for bridging the divide between the health care and housing sectors. While staff in these sectors often recognize the need to better integrate their services, there are few models for doing so. In this article we describe the formation of a health and housing consortium in the Bronx, New York City, as well as the successful replication of its model in Brooklyn. While each consortium has some features specific to its service area, the primary goal of both is the same: to provide a neutral space for health care and housing organizations to collaborate in what is otherwise often competitive and fragmented territory. In addition, the work of both consortia coalesces around training and resource development, cross-sector communication, and research and advocacy. We provide examples of the Bronx Consortium's activities in each of these core areas, highlight tangible results to date, and offer recommendations for people interested in undertaking similar efforts.