New Data Finds Health Care Organizations May Not Be Doing Enough to Connect Patients with Housing Services When They’re Needed Most.

Despite a 5-year-old law that requires hospitals in California to connect unhoused patients with social services, new data on patients in a large California-based health care system suggests that hospitals in the state are seldom making the connections to support their unhoused patients. Findings from researchers in Drexel University’s Dornsife School of Public Health suggest this is true even for some of the most medically vulnerable individuals: older adults, among whom homelessness is rising faster than any other demographic in the state.

The findings are based on an analysis of (anonymized) electronic health records for 119,127 adults aged 55 years and older, spanning 1,111,823 patient appointments from January 2013 through October 31, 2022. The paper, from researchers at Drexel, University of California, San Francisco and Boston University, was published today in the journal The Gerontologist.

Using the machine learning technique known as natural language processing to identify older adults experiencing housing insecurity, the team found that more than nine out of 10 patients in primary and/or emergency care who were housing insecure — 93% — were not referred to social services within six months.

Links to services, although rare, were more likely to occur in primary care than in emergency department care. Also, among those qualified for referral, Asian patients were less likely than white patients to be linked with appropriate housing services, even among those whose clinicians identified them as housing insecure. Just 0.6% (6,253) of patients were identified as housing insecure overall.

Five years ago, California’s state government passed SB 1152, mandating that hospitals make a personalized plan for unhoused patients before discharge, including referral to treatment programs or other community resources, such as health insurance, providing clothing and food, as well as transportation to their destination, as needed. But the study found no uptick in connections to social services since the law was passed.

“We’ve known for a long time that the public sector is letting tenants down: only a fourth of eligible renters get public housing assistance,” said senior author Gabriel Schwartz, PhD, an Assistant Professor in the Dornsife School of Public Health and the Urban Health Collaborative. “But we didn’t appreciate how much our health care sector is letting patients down, too: the fact that only 7% of older patients who are housing insecure are getting connected to social services should be a wake-up call.”

Problems facing unhoused community members in California and other states are complex and require complex solutions to address them. The authors speculate that the low number of referrals could stem from clinicians or social workers not having enough time or training to do referrals, or simply an understanding on the part of health care workers that there are insufficient resources outside of the hospital to assist these patients.

Unhoused patients in California face unique challenges, including competition for a limited number of shelter beds. In 2022, as the study period ended, San Francisco reportedly had just over half the beds needed for the city’s homeless population. From 2017 to 2021, California’s senior population grew by 7%, but the number of people aged 55 and older who sought out homeless services in the state skyrocketed by 84%.

As in many other states, California does not have nearly enough public housing to meet demand. Nor is the private housing market keeping pace: in the last 10 years, roughly 80,000 new homes were built each year—less than half of the 180,000 homes needed annually, according to the California Department of Housing and Community Development.

The researchers noted that those individuals who are unable to be sheltered and return to life on the street are at higher risk of ending up back in the hospital.

“We know that older adults are particularly vulnerable to asthma, infections and other health problems that are more likely to occur in unhoused populations,” said co-lead author Erin Ferguson, a PhD student at UCSF. “Compared to younger populations, older adults are more likely to face fewer job prospects, rely on a fixed income, and experience higher rates of chronic disease, along with many other health problems. It’s especially important to connect older adults who are unhoused with critical social services.”

The authors said that more standardized methods for determining which patients are housing insecure and reporting in health records would help institutions to monitor patients over time.

“There’s great potential for impact with reforms here, particularly among older adults in emergency rooms,” said co-lead author Shivani Mehta, a PhD student at UCSF. “We found that, even though housing insecure patients are more likely to be treated in emergency rooms than in primary care settings, primary care settings offered higher rates of housing referrals. Having this conversation with older adults while they’re in the emergency department could make all the difference.”

Although the number of housing insecure patients was determined using natural language processing and may therefore have identified some false positives or negatives, the number of housing insecure patients was consistent with other studies using the technique to determine housing status, and the numbers were also consistent with eviction trends in the general population in San Francisco (where the health care system the researchers studied is based).

Support for this study came from the National Institutes of Health.

Other than Schwartz, Ferguson and Shivani, other authors on the research include Silvia Miramontes, Minhyuk Choi, Tanisha G. Hill-Jarrett, Nicolas Cevallos, Yulin Yang, Scott C. Zimmerman, and Min Hee Kim from the University of California, San Francisco, and Ruijia Chen, Ye Ji Kim, and Kendra D. Sims from Boston University.