Mixed-Methods Evaluation of Emergency Department Use and Care Gaps Among Persons Experiencing Homelessness: Implications for Street Medicine

Persons experiencing homelessness (PEH) are high utilizers of emergency departments (ED). Wolverine Street Medicine (WSM) is a student-run organization offering medical care to PEH in Washtenaw County (WC) at Michigan Medicine. The purpose of this study is to describe how PEH utilize the ED and identify gaps in longitudinal care to inform services by WSM and reduce ED visits.

To characterize MMED utilization by PEH, quantitative data was obtained from June 2023-June 2024. Retrospective chart reviews of discharged PEH with ambulatory/non-substance use (ASNSU) conditions were analyzed for follow up and return visit characteristics. To understand follow up practices and barriers to care post ED discharge, 26 semi-structured interviews of hospital and community healthcare providers in WC were conducted and thematically coded.

During the study period, 2,738 PEH made 6,612 ED visits, of which 9.5% were for ASNSU conditions. Of these visits, 51.5% resulted in ED discharge. 169 unique PEH made an ASNSU visit that resulted in discharge; 44.4% were referred for a follow up appointment, of which only 17.3% attended. Of these discharged patients, 62.1% returned within 3 months, with an average of 6 return visits. Over a third (39%) of return visits had the same chief concern as the initial visit and 75% resulted in discharge. Attending a follow up visit was associated with statistically significant reduction in return ED visits at 3 months, compared to patients who did not follow up (p=0.0058, CI=-8.13 to -1.48). Thematic analysis of provider interviews found that lack of transportation, unknown address/phone for communication, limited patient centered care approaches, and lack of a central avenue to report unmet needs hinder access to follow up care. Respondents also noted that these factors contribute to increased ED visits by PEH.

This study explores PEH ED utilization in WC. Lack of follow up post ED discharge was associated with increased likelihood of ED return. Interviewees emphasized the need for flexible, patient centered interventions to improve care coordination, suggesting that WSM can serve PEH in WC by providing post ED visit follow-up care. Although the generalizability of the study is limited to a small Midwest city, the mixed methods analysis process can be applied to other communities to inform local street medicine and/or public health organizations.