Nearly half of more than 3,100 adult community health center patients surveyed between September 2014 and April 2015 had experienced housing instability, according to results published online Tuesday in the Journal of the American Medical Association. Among the issues reported, more than a quarter of respondents said they had moved two or more times over the past year, or who had difficulty paying their rent or mortgage. About 1.2% of those surveyed said they were currently homeless, a figure that was seven times higher compared to the rest of the US population.
About 9% of respondents said they lived in a place they themselves did not rent or own, while more than 6% said they had stable housing now but had been homeless in the past.
Study authors recommended community health center providers universally ask patients about their housing status—which has increasingly been tied to poor health outcomes. The analysis found those who said they had housing problems were more likely to report health problems, increased use of emergency departments and delays in getting medical care and medications compared to patients who never experienced housing problems.
“Identifying housing problems among CHC patients could offer at least two avenues for action,” said study co-author Dr. Travis Baggett, a faculty clinician investigator in Massachusetts General Hospital’s division of general internal medicine and a staff physician at Boston Health Care for the Homeless program.
Baggett said screening patients would flag who benefits from social service referrals while also informing clinicians how acute and chronic health conditions would be managed.
“Patients with housing problems may have difficulty storing and taking medications, may have limited control over their dietary intake or sleeping conditions, and may lack a stable place to recover from acute illnesses,” Baggett said. “Each of these scenarios requires some problem-solving and work-arounds that are tailored to patients’ living circumstances—unless clinicians are aware of these background housing problems, any given treatment plan risks being at odds with the realities of a patient’s day-to-day life.”
CHC providers were not surprised by the study’s findings.
At Family Health Centers, Inc., a six-site community health center network located in the Louisville, Kentucky area, roughly 10% of the 40,000 patients that visit every year are typically considered homeless, said communication director Melissa Mather.
Since 1988, the center has operated a clinic where homeless patients receive primary care services as well as housing assistance. Across the country, 295 health centers received federal grant support under HRSA’s Health Care for the Homeless Program in 2015 according to the National Association of Community Health Centers. Collectively, programs served over 890,000 homeless people, including over 110,000 children.
“If you’re living in a shelter or living on the street, your number one priority is not your health,” said Andy Patterson, director of Family Health Center’s Health Care for the Homeless program. “Your number one priority is just getting through the day, so it’s sometimes very difficult for them to comply with the treatment based on their housing situation.”
According to Amy Simmons Farber of the National Association of Community Health Centers, clinics that receive federal grant funding routinely universally screen for housing status as part of their data reporting requirements to the Health Resources and Services Administration. But Farber acknowledged that some clinics need help integrating that information into their clinical health records. Still other providers felt asking a question about housing in some standardized form could make some patients uncomfortable and discourage them from answering.
“I think ultimately it comes down to that one-on-one conversation that you have with a patient,” said Dr. Nimmi Rajagopal, assistant professor of clinical family medicine at the University of Illinois at Chicago and a site medical director of Mile Square Health Center, a federally qualified health center with six clinic sites throughout Chicago.
A social service worker is onsite at the clinic to help patients connect with resources. Rajagopal said clinicians at Mile Square are taught to bring up the topic of housing during their private conversations with patients. “I think there may be some limitation with universal screening because the patient may not feel comfortable answering that question with just anybody.”