Effects of Housing Instability upon Treatment Adherence Among Children and Youth with Special Health Care Needs

Background: Treatment adherence is critical for positive health outcomes in children and youth with special health care needs (CYSHCN), yet it is often compromised by social determinants of health. Housing instability, which encompasses frequent moves, eviction risks, and substandard living conditions, can disrupt stable insurance coverage and undermine families’ capacity to manage appointments. Children with medically complex conditions are particularly susceptible to these disruptions. This study assesses the prevalence of housing instability and its association with missed appointments in a large pediatric health system serving CYSHCN.

Methods: Data and samples: We analyzed 21,081 CYSHCN who received care from 2021 to 2023 at a flagship hospital and 14 affiliated clinics in the northeastern United States. The Centers for Medicare and Medicaid Services’ Accountable Health Communities Health-Related Social Needs Screening Tool was administered online prior to visits to capture key data on housing and other social needs.

Measures: The primary outcome, treatment adherence, was defined by whether the first observed scheduled appointment during the study period was kept or missed. Housing instability was self-reported (“Do you have steady housing?”). Other variables included the child’s age, race/ethnicity, insurance type, visit mode (in-person or telemedicine), visit type (evaluation, follow-up, therapy, or testing), and distance traveled.

Analytic Strategy: We conducted univariate analyses to summarize sample characteristics, followed by bivariate analyses to examine associations between housing instability and appointment adherence. Logistic regression was used to estimate the odds of missed appointments, adjusting for demographic, insurance, visit-related, and distance factors.

Results: Of the 21,081 participants, 2,725 (12.9%) reported unstable housing. Overall, 3,538 (16.8%) did not keep a scheduled appointment. Patients with housing instability had 22% higher odds of missing an appointment (OR: 1.22; 95% CI: 1.10, 1.35; p < .001). Missed appointments were also more common among Black and Hispanic/Latino children, those with public or self-pay insurance, and children who had a follow-up or therapy visit. In contrast, older children (especially ages 15 and up) and those using remote (telemedicine) visits were less likely to miss scheduled care. Longer travel distance marginally increased the odds of missed appointments.

Conclusions and Implications: Housing instability is a significant predictor of poor treatment adherence in CYSHCN, adding to racial, economic, and logistical barriers that impede consistent care. These findings underscore the importance of addressing both medical and social needs in healthcare settings, where interventions like telehealth expansion, screening for unmet social needs, and robust community partnerships can improve access. Health systems and policymakers should prioritize integrated strategies that tackle underlying SDoH, including housing challenges, to ensure more equitable care and better outcomes for children with special health care needs.