Navigating the Boundaries of Emergency Department Care: Addressing the Medical and Social Needs of Patients Who Are Homeless

摘要

Objectives. We sought to understand interpersonal and systems-level factors relevant to delivering health care to emergency department (ED) patients who are homeless. Methods. We conducted semistructured interviews with emergency medicine residents from 2 residency programs, 1 in New York City and 1 in a medium-sized northeastern city, from February to September 2012. A team of researchers reviewed transcripts independently and coded text segments using a grounded theory approach. They reconciled differences in code interpretations and generated themes inductively. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. Results. From 23 interviews, 3 key themes emerged: (1) use of pattern recognition in identifying and treating patients who are homeless, (2) variations from standard ED care for patients who are homeless, and (3) tensions in navigating the boundaries of ED social care. Conclusions. Our study revealed practical and philosophical tensions in providing social care to patients in the ED who are homeless. Screening for homelessness in the ED and admission practices for patients who are homeless are important areas for future research and intervention with implications for health care costs and patient outcomes. More than 1.5 million people experience homelessness in the United States every year. 1 Homelessness is associated with high levels of chronic illness and morbidity, 2–4 unmet health needs, 5–8 and difficulties in accessing primary care. 9,10 People who are homeless use the emergency department (ED) at higher than average rates, 11 even when compared with other low-income populations. 12–14 Furthermore, people who are homeless are disproportionately represented among frequent users of the ED. 12,15,16 For example, an analysis at 1 urban hospital found that 38% of patients with 5 or more ED visits per year were homeless. 15 Most studies pertaining to homelessness and ED use have focused on predictors of ED use, identifying such correlates as medical comorbidities, mental illness, substance abuse, crime, and food insecurity. 14,17–22 Fewer studies have examined basic descriptive information about ED visits by patients who are homeless. One national survey showed that ED patients who were homeless had triage urgencies and hospital admission rates comparable to those of other patients but were more likely to have arrived by ambulance. 23,24 A paucity of research, however, has examined in any detail the ED care received by patients who are homeless. Significant knowledge gaps exist about potential challenges related to ED care of patients who are homeless, including the response to their medical and social needs and any differences in their care compared with that for other patients. Improving ED care for patients who are homeless without first understanding the unique interpersonal and systems-level challenges in providing such care will be difficult. To this end, we aimed to explore providers’ perceptions of ED care for patients who are homeless using semistructured interviews with emergency medicine resident physicians (“residents”) as key informants. We sought to gain meaningful insight into the multifaceted processes of delivering health care to patients who are homeless in the ED to guide improvements in current practice and generate hypotheses that can be further explored in future research.