A Mixed-Method Study of the Implementation of a Two-Question Screening Protocol Assessing Homelessness and Housing Insecurity in an Urban Emergency Department

Abstract

Abstract Background Hospital screenings for social determinants of health are becoming more prevalent. Although Senate Bill 1152 mandated a homelessness screen within California hospitals and the Veterans Health Administration has a housing screen in outpatient clinics, neither the Veterans Health Administration nor California hospitals have evaluated the screening question wording. The current study examines the process of implementing a screen for homelessness and housing insecurity in an urban Emergency Department (ED) with a Level 1 trauma center. Patients who screened positive were referred to social workers for assistance. We describe resulting changes in procedures and evaluate alternative screening questions. Methods This paper consists of two studies. For Study 1, from November 2022 to March 2023, we conducted qualitative interviews with 26 registration, social worker (SW), and physician ED staff, with iterative modifications to procedures created in response through February 2024. We also conducted a focus group of people with lived experience to gather their perspective on the screening questions. Because Study 1 uncovered concerns with question wording, we tested the predictive efficacy of different questions in quantitative Study 2 in Fall 2023. Results For Study 1, registration staff reported that the two-question screening integrated into their workflow well, but was complex. SWs reported that they engaged with more patients, felt more comfortable navigating resources, and could follow up with patients during subsequent ED visits. Physicians reported care adaptations for patients they believed homeless; however, they did not use the screening information. For Study 2, altered wording led to fewer patients screening positive and fewer true positives as evaluated by SWs but a higher positive predictive value. Conclusion The modified screening process was acceptable within registration and SW workflows and did not directly impact physician workflow. Our screening process lays the groundwork for improving care for patients facing homelessness and housing insecurity.