O0022: Child Homelessness and Emergency Department Utilization

Background: Children who experience homelessness face greater risk of acute health problems and barriers to healthcare access. Prior studies that have noted higher emergency health services utilization among children experiencing homelessness were largely conducted over two decades ago and limited to single institutions or localities. Our objective was to determine associations of homelessness with emergency department (ED) utilization patterns across a broad population of children.

Methods: We conducted a cross-sectional study using the Healthcare Cost and Utilization Project State Emergency Department Database and State Inpatient Database of New York from 2014 to 2018. All children less than 18 years old with a visit to an ED were included. Children were identified as experiencing homelessness if they received either a database designation or a diagnosis code of homelessness for any visit in a given year. Characteristics of age, race/ethnicity, insurance type, and medical complexity as measured by the Pediatric Medical Complexity Algorithm were examined for children experiencing homelessness compared to their housed counterparts. Between groups we compared proportions of children with frequent ED utilization, defined as 4 or more ED visits in one year, and incidence rates of ED visits for ambulatory care sensitive conditions (asthma, diabetes, gastroenteritis, and urinary tract infection), injuries and poisonings, and mental and behavioral health problems. Associations of homelessness with rates of admission from ED visits were also evaluated.

Results: Statewide between 2014 and 2018, an average of 928,056 children each year visited an ED, of whom 2,917 (0.3%) were identified as experiencing homelessness. Compared to their housed counterparts, greater proportions of children experiencing homelessness were non-Hispanic Black (37.2% for homeless versus 21.7% for housed) or Hispanic (37.9% versus 21.5%) and publicly insured (90.2% versus 56.7%). Both noncomplex (25.9% versus 9.2%) and complex chronic disease (13.8 versus 3.4%) were more common among children experiencing homelessness (Table). Homelessness was associated with a significantly higher proportion of frequent ED utilization (21.2% versus 4.3%) and higher incidences of ED visits for ambulatory care sensitive conditions and mental and behavioral health problems (Figure). Children experiencing homelessness had significantly higher admission rates from the ED overall (43.0% versus 6.0%) and to the intensive care unit specifically (4.3% versus 0.8%).

Conclusion: Children experiencing homelessness have high ED utilization, with their visits frequently resulting in hospitalization. Addressing the health and social needs of this population warrants attention from health systems and policymakers seeking to alleviate disparities in child health and healthcare utilization.