Performance of 2 Single-Item Screening Questions to Identify Future Homelessness Among Emergency Department Patients

Abstract

ImportanceDespite increasing interest in assessing patient social needs in health care settings, there has been little research examining the performance of housing-related screening questions.ObjectiveTo examine the performance of 2 single-item screening questions assessing emergency department (ED) patients’ self-perceived risk of future homelessness.Design, Setting, and ParticipantsThis prospective cohort study was conducted among a randomly selected sample of adult ED patients from 2016 to 2017 in a public hospital ED in New York City. Data were analyzed from September 2019 through October 2021.ExposuresResponses on patient surveys conducted at the baseline ED visit for 2 single-item screening questions on self-perceived risk for future housing instability and homelessness were collected. One question asked patients if they were worried about having stable housing in the next 2 months, and the other question asked them to rate the likelihood that they would enter a homeless shelter in the next 6 months.OutcomesHomeless shelter entry 2, 6, and 12 months after an ED visit, assessed using shelter administrative data in the study city, which was linked with participant baseline survey responses.ResultsThere were 1919 study participants (976 [51.0%] men and 931 [48.6%] women among 1915 individuals with gender data; 700 individuals aged 31-50 years [36.5%] among 1918 individuals with age data; 1126 Hispanic or Latinx individuals [59.0%], 368 non-Hispanic Black individuals [19.3%], and 225 non-Hispanic White individuals [11.8%] among 1908 individuals with race and ethnicity data). Within 2, 6, and 12 months of the ED visit, 45 patients (2.3%), 66 patients (3.4%), and 95 patients (5.0%) had entered shelter, respectively. For both single-item screening questions, participants who answered affirmatively had significantly higher likelihood of future shelter entry at each time point examined (eg, at 2 months: 31 participants responding yes [6.5%] vs 14 participants responding no [1.0%] to the question concerning being worried about having stable housing in the next 2 months). Sensitivity of the screening questions ranged from 0.27 to 0.69, specificity from 0.76 to 0.97, positive predictive value from 0.07 to 0.27, and area under the receiver operating characteristic curve from 0.62 to 0.72.Conclusions and RelevanceThis study found that 2 single-item screening questions assessing ED patient self-perceived risk of future housing instability and homelessness had adequate to good performance in identifying risk for future shelter entry. Such single-item screening questions should be further tested before broad adoption.

ED‐Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use

“…On the other hand, past research has also shown that individuals seeking homelessness prevention services do not always accurately predict their risk for future homelessness (e.g., they may overestimate their need for such services), which can result in inefficiencies in service provision 43 . Future ED studies could consider a two‐stage process combining use of a screening tool—potentially even a single‐item screener 44 —with a question ascertaining self‐perceived risk or need for the intervention 45 …”

“…42 On the other hand, past research has also shown that individuals seeking homelessness prevention services do not always accurately predict their risk for future homelessness (e.g., they may overestimate their need for such services), which can result in inefficiencies in service provision. 43 Future ED studies could consider a twostage process combining use of a screening tool-potentially even a single-item screener 44 -with a question ascertaining self-perceived risk or need for the intervention. 45 Our pilot study focused on the subpopulation of ED patients with drug and unhealthy alcohol use; these factors confer additional individual risk beyond the primary structural drivers of homelessness (i.e., lack of affordable housing).…”

Optimising Access to Healthcare for Patients Experiencing Homelessness in Hospital Emergency Departments

“…Lengthy screening tools can be burdensome in a busy ED context, and brief screening questions prevent disrupting the ED workflow but need to be evidence-based [40]. Recently a two-item self-rated questionnaire has been trialled and found to have acceptable sensitivity [41]. As screening for health risks or social factors may be perceived by patients as stigmatising, it is critical that any screening in an ED is performed in a non-judgmental way and avoids any risk of a negative experience for patients or staff [40].…”