From Their Perspective: The Connection between Life Stressors and Healthcare Service Use Patterns for Homeless Frequent Users of the Emergency Department

Background and Purpose: Understanding patient perspectives on their emergency department (ED) utilization is important to define modifiable targets for intervention. However, the perspective of homeless adults is largely absent from the literature. We highlight the viewpoints of homeless frequent users of the ED about the influence of life events on ED utilization.

Methods: We conducted in-depth, semi-structured interviews with a purposive sample of 18 homeless persons who frequented the ED (>4 visits in 6 months). We recruited racially and ethnically diverse participants. Interviews were audio recorded and transcribed verbatim. Data were analyzed in Dedoose by three coders using qualitative content analysis. Medical record data were analyzed and triangulated with interview data to discern patterns of healthcare utilization.

Results: Participants reported high levels of pain and comorbid psychiatric, substance use, and medical conditions. Participants reported an identifiable pattern of healthcare utilization (often centered on a crisis event) influenced by high perceived medical needs (chronic illness, substance use, and mental health), ability to cope after crisis, predisposing vulnerability from social determinants of health (history of trauma, incarceration), and healthcare system factors (proximity/convenience, consistency, trust in ED, unknown ED alternatives). A case management intervention often led to a period of stability and use of ED alternatives.

Conclusions: Modifiable targets for intervention at the provider and healthcare system levels were identified, including targeting interventions at time of crisis event, referral to social work, creating close partnerships between ED and community clinics, public health campaigns to advertise and link patients to outpatient alternatives to the ED, improving consistency of providers at clinics to increase trust, improving pain management models at clinics, and co-locating social services at clinics.