Housing Instability Increases Likelihood of Discharge Against Medical Advice
By Stacey Kusterbeck
Patients managing alcohol use disorder and substance use disorder are at high risk for discharge against medical advice.1,2 Caitlin Ryus, MD, MPH, and colleagues wanted to know if the same was true for patients with housing instability.
Researchers analyzed data collected in the Healthcare Cost and Utilization Project on more than 85 million hospitalizations that happened from 2017 to 2019. For admissions with planned discharges, 1.1% coded housing instability. For self-discharges, 5.4% of patients coded housing instability. Housing instability significantly increased the likelihood of self-discharges, particularly in cases of major medical conditions with high potential for morbidity and mortality, such as sepsis, respiratory failure, and acute myocardial infarction.3
The data were limited to inpatient stays. “But there are numerous takeaways from an ED perspective. As an ED physician, we can play a critical role in mitigating the risk of self-discharge in the patients that we admit,” underscores Ryus, an instructor in the department of emergency medicine at Yale School of Medicine.
It is important for emergency medicine providers to recognize that patients facing housing instability might be more inclined to self-discharge, even when dealing with severe medical conditions. Ryus suggests several practice changes:
• Implement screening processes to identify housing instability. ED staff can do this by asking targeted questions or using standardized assessment tools. Where did you sleep last night? Do you have a stable place to stay? Is where you are staying a safe environment? Ryus says it is a good idea to ask all ED patients about their housing circumstances. “Even for housed patients, knowing the home environment helps you assess their ability to follow a care plan," Ryus says.
• Consult social workers or care coordination early in the ED encounter. This is helpful regardless of whether a patient is going to be discharged from the ED or admitted to the hospital.
“Social workers or care coordinators can help patients navigate the impact a hospitalization may have on their eligibility for community resources, shelters, or support services,” Ryus explains.
Some patients want to leave the ED specifically because of a housing concern. Social workers can call to assess availability of shelter beds; help patients navigate local resources; assess the possibility of respite placement; and, if there is a curfew at the shelter, help secure a spot while the patient finishes the ED workup.
• Explain the importance of continued medical care and the potential risks of self-discharge. This is especially important for ED patients with serious medical conditions. “Patients have agency to make their own medical decisions, and an imminent threat to a person’s housing is a very compelling priority,” Ryus says. “But there are ways to make the situation safer.”
Providers can arrange follow-up appointments, offer necessary prescriptions, give instructions for when to return to the ED, and clarify that the patient is welcome to return, if needed. Ryus says emergency care providers should engage in patient-centered communication, and consider the real challenges the patient is facing with housing instability.
“This is another place where social work and care coordination can help both providers and patients, by problem-solving ways to stay in the hospital,” Ryus offers.
• Engage patients in shared decision-making regarding their treatment plans. “When patients are involved in decisions about their care, they may be more likely to follow through and stay in the hospital,” Ryus suggests.
• Document discussions about housing instability and self-discharge risks using nonjudgmental language. Stick to the facts and record the patient’s concerns about housing instability without editorializing.
The ED chart should note any referrals provided and the patient’s understanding of the potential consequences of leaving.
“Clear documentation helps the inpatient team, consultants, and any future providers tailor care to patient needs,” Ryus explains.
1. Simon R, Snow R, Wakeman S. Understanding why patients with substance use disorders leave the hospital against medical advice: A qualitative study. Subst Abus 2020;41:519-525.
2. Coleman R, Coulton S, Phillips T. Factors associated with discharge against medical advice in alcohol withdrawal patients. Alcohol Alcohol 2023;58:561-564.
3. Ryus CR, Janke AT, Kunnath N, et al. Association of hospital discharge against medical advice and coded housing instability in the US. J Gen Intern Med 2023; Jun 27.
It is important for emergency medicine providers to recognize that patients facing housing instability might be more inclined to self-discharge, even when dealing with severe medical conditions.
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