Homeless Pediatric Patients Use EDs Frequently
By Stacey Kusterbeck
Frequent ED visits occur for 22% of children experiencing homelessness, compared to just 4% of children who are housed.1
“Our larger aim was to draw renewed attention to health disparities affecting children experiencing homelessness,” says Lawrence Chang, MD, the paper’s lead author and a clinical fellow in pediatric emergency medicine at Boston Children’s Hospital.
Thousands of children in the United States experience homelessness at any point in time. “Yet surprisingly, little recent research attention has been paid to their healthcare needs,” Chang reports.
Most of the studies the researchers found on this topic were from the 1990s or earlier, according to Chang. “The literature wanes significantly after this time,” he adds.
Chang and colleagues set out to provide an updated exam of ED use by homelessness status across a statewide population of children. Some key findings:
• Children experiencing homelessness frequently used EDs, defined as four or more visits in a calendar year, compared to housed children. “Frequent ED use is often regarded as a marker of poor health,” Chang notes.
• Children experiencing homelessness required hospitalization more often than housed children when they visited the ED, including to ICUs. “These findings underscore the critical influence of housing as a social determinant of health,” Chang says.
One of the challenges with research on family and child homelessness has been a lack of reliable data collection. Identification of homelessness among ED patients could improve with standardized screening tools, according to Chang. While some EDs perform social screening, this is not a universal practice. “ED providers may document a patient’s housing problems in their note — or, better yet, with a diagnosis code related to homelessness,” Chang suggests.
ED providers can treat acute illnesses, and can take steps to provide social referrals to meet the needs of children experiencing homelessness. However, reducing ED use will require broader interventions to improve the health of these children even before they visit EDs, asserts Chang, which he says includes expanded access to ambulatory care.
ED-based interventions to prevent revisits include initiatives to schedule follow-up visits with primary care physicians. This can happen during or immediately after ED visits. Other EDs provide follow-up phone calls after visits to help families experiencing homelessness navigate accessing ambulatory care services. “It should be noted that these interventions seem to have limited effectiveness in reducing revisits, underscoring that EDs cannot do it alone,” Chang laments.
There is scant literature on ED-based interventions specifically for children experiencing homelessness, notes Chang. “This is likely due to the inherent barriers posed by the episodic nature of ED care,” he offers.
EDs that care for many children experiencing homelessness may explore establishing dedicated teams of social workers to help patients connect with local housing and social service agencies.
Lack of continuity is the central risk for ED pediatric patients who are homeless, says Jonathan M. Fanaroff, MD, JD, professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland. Patients often lack a “medical home” where they are obtaining comprehensive preventive care.
“The ED is not designed to provide such care,” says Fanaroff. “Lack of continuity over several visits may increase the risk of missing a diagnosis; that, in turn, leads to a malpractice lawsuit.”
1. Chang L, Stewart AM, Kester K, et al. Association of homelessness with emergency department use among children in New York. JAMA Pediatr 2023 Apr 10;e230478. doi: 10.1001/jamapediatrics.2023.0478. [Online ahead of print].
Homeless children frequently use EDs, defined as four or more visits in a calendar year, compared to housed children. These patients require hospitalization more often than housed children when they visited the ED, including to ICUs. This underscore the critical influence of housing as a social determinant of health.
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