Emergency department linkage to care for patients experiencing homelessness

The Department of Health and Human Services awarded a $186,728 Project Grant to the Denver Health and Hospital Authority under the National Research Service Awards Health Services Research Training program (CFDA 93.225). This grant will fund the design, implementation, and evaluation of a novel intervention to refer people experiencing homelessness from the emergency department to a physician-led street medicine program at the time of discharge. The goal is to improve health outcomes and reduce unnecessary emergency department utilization for this vulnerable population. The project aims to understand the facilitators and barriers to linkage-to-care after emergency department discharge, and to assess the feasibility and effectiveness of the ED-based referral intervention. The project will utilize conceptual frameworks such as PRISM, RE-AIM, and health equity to guide the research.

Abstract

In 2023, nationwide rates of homelessness reached the highest levels since 2007, with over-representation of racial, ethnic, and gender minorities and unsheltered homelessness reaching record highs. Emergency departments (EDS) serve as a critical healthcare safety-net, and people experiencing homelessness (PEH) disproportionately utilize ED services compared to the general population. PEH suffer from fragmented care, often lacking primary care and seeking services from multiple healthcare systems, contributing to high rates of delayed care, morbidity, and mortality. A potential solution to such fragmented care is "street medicine", which provides mobile primary care services to PEH on the streets, in shelters, and in encampments, and has been shown to enhance patient engagement, improve access to housing, and decrease ED utilization and hospitalizations. While use of street medicine is a promising solution to the fragmented care, health care needs, and unnecessary ED over-utilization of PEH, thus far there have been no studies on the feasibility or effectiveness of a linkage-to-care intervention between EDS and street medicine programs at the time of ED discharge. Therefore, we aim to design, implement, and evaluate a novel ED-based intervention referring PEH to a physician-led street medicine program for follow-up at the time of ED discharge, with the overarching goal of improving health while decreasing unnecessary ED utilization. Our aims therefore are (1) to understand facilitators and barriers of linkage-to-care after ED discharge for PEH through patient and stakeholder perspectives, and (2) to implement and evaluate the feasibility and effectiveness of an ED-based intervention referring PEH to direct follow up with a physician-led street medicine clinic at ED discharge. Utilizing the prism, RE-aim and health equity conceptual frameworks, we will identify themes of facilitators and barriers of linkage-to-care for PEH through semi-structured interviews and focus groups during aim 1. These findings will inform aim 2 and our hypotheses that (1) at least 60% of eligible participants will be successfully identified and referred to either the street medicine program or conventional follow-up as standard of care, and (2) a novel ED-based street medicine referral will be significantly associated with successful follow-up when compared to referral to conventional follow-up as a standard of care. This individual national research service award (nrsa) will provide an exceptional platform to accelerate the training of kathleen joseph, MD as an early- stage health service research and implementation scientist focusing on care coordination for PEH. She will receive support from a diverse team of experienced mentors within a nationally recognized safety-net healthcare system. Training and research conducted as part of this award will inform a subsequent mentored career development award (K08) application to ahrq with the goal of improving continuity of care for PEH in the ED.