Housing Instability and Longitudinal Health Care Access in a Safety-Net Emergency Department

Housing instability is associated with reduced engagement in primary and longitudinal care. Patients with unstable housing often rely on emergency department (ED) services, which rarely translate into outpatient follow-up. We examined the association between housing instability and longitudinal healthcare access in a safety-net ED population.

A cross-sectional survey was conducted at an urban safety-net ED across three academic terms (Summer 2024, Spring 2025, Summer 2025). Adult ED patients (≥18 years) speaking English or Spanish were included. Patients with altered mental status, intoxication, critical illness, custody, or psychiatric hold were excluded. Housing instability was defined by self-report of stable versus unstable housing during the prior two months (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences [PRAPARE]; Accountable Health Communities–Health-Related Social Needs [AHC–HRSN]). Strong longitudinal access to care was defined as having a usual source of non-ED care and a consistent care site (Consumer Assessment of Healthcare Providers and Systems [CAHPS]). Multivariable logistic regression estimated unadjusted and adjusted odds ratios (OR), adjusting for age, gender, and education.

Among 1,173 patients included in adjusted analyses, mean age was 48.7 years (SD 15.8), and 54.1% were male. Strong longitudinal access to care was observed in 56% of stably housed patients compared with 40% of unstably housed patients (p<0.001). In unadjusted analyses, unstable housing was associated with lower odds of strong longitudinal access (OR 0.51, 95% CI 0.37–0.71, p<0.001). After adjustment, unstable housing remained significantly associated with lower odds of strong longitudinal access (OR 0.54, 95% CI 0.38–0.75, p<0.001).

Housing instability is associated with lower odds of longitudinal care access among patients presenting to a safety-net ED. Interventions addressing housing instability may improve continuity of care. Limitations include self-reported data and single-site design.