Dedicated homeless clinics reduce inappropriate emergency department utilization

Abstract

Background The homeless patient population is known to have a high occurrence of inappropriate emergency department (ED) utilization. The study hospital initiated a dedicated homeless clinic targeting patients experiencing homelessness with a combination of special features. We aim to determine whether this mode of care can reduce inappropriate ED utilization among homeless patients. Methods We conducted a retrospective observational study from July 1, 2017 to Dec 31, 2017. The study enrolled all homeless patients who visited any hospital regular clinic, dedicated homeless clinic, and ED at least once during the study period. ED homeless patients were divided into four groups (A: no clinic visits; B: those who only visited hospital regular clinic; C: those who only visited dedicated homeless clinic; and D: those who visited both hospital regular clinic and dedicated homeless clinic). The New York University algorithm was used to determine appropriate ED utilization. We compared inappropriate ED utilization among patients from these groups. Multivariate logistic regression was used to determine the risks of different clinical visits in association with inappropriate ED utilization. Results A total of 16,323 clinic and 8511 ED visits occurred among 5022 unique homeless patients, in which 2450 unique patients were seen in hospital regular clinic, 784 patients in dedicated homeless clinic, 688 patients in both hospital regular clinic and dedicated homeless clinic, and 1110 patients with no clinic visits. Twenty‐nine percent (230/784) of patients from dedicated homeless clinic utilized the ED, among which 21% (175/844) of their ED visits were considered inappropriate. In contrast, 40% of patients from hospital regular clinic utilized the ED, among which 29% were inappropriate ( P < 0.001). The adjusted odds ratio (OR) was 0.61 (95% confidence interval [CI] = 0.50–0.74, P < 0.001) on dedicated homeless clinic predicting inappropriate ED visits in multivariate logistic regression. Conclusion Implementing a dedicated homeless clinic with these features can reduce ED inappropriate utilization among patients experiencing homelessness.

Invited Editorial: Dedicated homeless clinics and emergency department utilization: a new horizon?

“…The results presented by Wang et al 1 can help to inform policies that meet the unique and complex health care needs of the population of persons experiencing homelessness, particularly in the setting of acute, unscheduled care. Further study is necessary to determine whether the “bricks and mortar” availability of a dedicated space or the focus on specific services were associated with the reduction in ED use reported in the paper.…”

“…Further study is necessary to determine whether the "bricks and mortar" availability of a dedicated space or the focus on specific services were associated with the reduction in ED use reported in the paper. In addition to the dedicated primary care physicians and street outreach teams described by Wang et al, 1…”

“…In this issue, an article by Wang et al, 1 “Dedicated Homeless Clinics Reduce Inappropriate Emergency Department Utilization,” describes the impact of a “bricks and mortar” dedicated homeless clinic compared to a regular hospital clinic on reducing inappropriate emergency department (ED) utilization by persons experiencing homelessness. This single‐center study of over 5000 subjects over a 12‐month period in Fort Worth, Texas, suggests that the dedicated homeless clinic reduced ED use by persons experiencing homelessness.…”

“…Further study is necessary to determine whether the “bricks and mortar” availability of a dedicated space or the focus on specific services were associated with the reduction in ED use reported in the paper. In addition to the dedicated primary care physicians and street outreach teams described by Wang et al, 1 stigma prevention and the availability of specialty care that meets the needs of this population could maximize the value of a dedicated homeless clinic located near a homeless shelter. These services should include mental health and substance abuse resources (including access to psychiatrics and psychologists), as well as robust care management services imbedded into the dedicated homeless clinic.…”

“…The ED can provide acute, episodic care but is only one component of meeting the needs of persons experiencing homelessness. ED screening for homelessness and housing insecurity might help to identify individuals who might benefit from the ongoing care available at a dedicated homeless clinic as described by Wang et al 1 . Screening could be integrated into regular ED care and should not negatively impact patient care or create additional administrative burdens on an already strained emergency care system.…”