Homeless High Users of the Emergency Department: Understanding the Relationship Between Life Stress and Emergency Department Use

Abstract

Background: Patients who frequently use Emergency Department (ED) services are particularly vulnerable to poor health outcomes and have high healthcare costs. Homeless high users have particularly complex healthcare needs and increased difficulty in using and accessing healthcare. To determine modifiable targets for intervention, understanding patient perspectives on their healthcare service use must first occur; however, patient perspectives, especially those of homeless high users, have been absent from the literature. Aim: To describe the views of homeless high users of the ED about the influence of life experiences on their ED use. Methods: Researchers conducted in-depth, semi-structured interviews with 18 homeless persons with more than four ED visits in the six months prior to interview date. Interviews were audio recorded and transcribed verbatim for analysis in Dedoose by three coders. Qualitative analysis was performed in three phases—open, axial, and selective—to illuminate final themes. Quantitative data from medical records triangulated interview data and interviewer notes. Results: In describing the pattern of use by homeless high users, four domains emerged: a (1) crisis moment leads to increased ED use, which warrants an (2) intervention that (3) stabilizes patients for a period; (4) predisposing instability impacts both whether a crisis moment will occur and the degree to which a crisis moment impacts ED use. Conclusions: This work contributes to understanding the multitude of factors that impact ED use among the most vulnerable patients, which is the first step in elucidating promising interventions. Future interventions should consider expanding evidence-based case management programs. The next research step is to standardize a set of data socioeconomic data elements to determine which patients warrant intervention immediately after a crisis point rather than after ED use has drastically increased.