ED Clinicians Tackle Patients’ Food Insecurity, Homelessness

PHILADELPHIA — Emergency departments trying to help patients with social problems such as food insecurity and housing insecurity are meeting with varying degrees of success, according to reports from researchers here at the annual meeting of the American College of Emergency Physicians.

Although screening in the emergency department for food insecurity is becoming more common, “many patients experience difficulty in connecting to the resources that we refer them to,” Alex Ulintz, MD, of the Ohio State University in Columbus and formerly a resident at Indiana University in Bloomington, said Tuesday.

To address that problem, two approaches are frequently suggested, he said. “One has been something like a food bank program; we have a pre-made bag of food, and if you screen positive, we get that to you. Another potential approach is can we have a food pantry or other resources that are in or near the ED, and that’s something that our group was interested in.”

To find out how effective the latter approach might be, Ulintz and colleagues at Indiana University studied whether patients would accept and use a $30 food voucher for the university hospital’s “Fresh for You” market, a store designed to give patients and hospital employees better access to fresh fruits and vegetables. The market is located between the emergency department and the nearest bus stop, and can be reached by walking less than a tenth of a mile from the ED using the shortest possible route.

The researchers looked at adults seen in the emergency department from July through October of 2022, between the hours of 8 a.m. and midnight. They administered a two-question screening tool known as the Hunger Vital Sign, which asks the patient if, any time during the past 12 months, they’ve ever been worried about running out of food before they were able to get money to buy more and whether that scenario had ever actually happened during that period. A positive response to either question (or both) was considered a positive screen and triggered an offer for a food voucher, Ulintz explained.

They found that of 377 patients who completed the screening tool, 277 screened positive for food insecurity, and of those, almost all of them (224) accepted the food voucher. However, only 87 of them used the voucher, which was disappointing, Ulintz said. Those who used the voucher had a median redemption time of 9 days, which “was unexpected and did not really correlate with what we were seeing in the primary health [division],” which has a similar program.

“Sometimes this can be really frustrating. This program works everywhere else; why doesn’t it work in the ED?” he said. “But I think it highlights some really important conceptual questions when a health system tries to take something that was designed for primary care and plops it down in the ED to see what happens … The positive here is that from a public health standpoint, patients seem open to not only screening in the emergency department, but also accepting resources that are physically given to them.”

In Louisville, Kentucky, meanwhile, researchers want to know how to better serve unhoused patients. Homelessness is a big problem in Louisville, affecting about 10,000 residents, said Kyle Stucker, MD, of the University of Louisville School of Medicine. In addition to making more frequent ED visits compared with other patients, unhoused patients “often have a far higher mortality rate and a lower standard of living and life expectancy.”

To find out how clinicians felt about this issue, the researchers deployed a survey to emergency department physicians and nurses at their hospital. In addition, they conducted interviews with 24 community members who represented important stakeholders on this topic. They also held a public meeting involving both the ED staff and community stakeholders to help formulate guidelines for addressing homelessness.

The survey found that 82.2% of clinician respondents felt confident they could identify a patient experiencing homelessness, and 80% agreed with the statement, “Over the past month, I have provided quality, comprehensive care to patients experiencing homelessness.” However, although 66.8% said they had witnessed stigma toward unhoused patients from another coworker, only 40% said they had done so themselves, “so there’s a little bit of an imbalance there,” said Stucker. “And I think that there’s a difference specifically because people are often not realizing that they themselves are exhibiting stigma in their personal interactions.”

“Overall, the stigma that the homeless face in the emergency department provides the largest barrier to care,” he added. “If you spend less time with that person, if you have all these predisposed judgments against that person, they’re unlikely to receive the same quality of care and maybe not get good resource communication for how they can plug themselves into local environments.”

Homelessness “is a very complex social, political, and health issue,” said Stucker. To solve the problem, “we need collaboration amongst the stakeholders and all of our local communities, and the medical professionals as well.” To help meet the homeless where they are — in places like the ED — one idea the stakeholders came up with was to create “a standardized, easy-to-read and easy-to-use resource packet that we would distribute to all the different healthcare facilities around the city … We’re going to try to give that a test run and see how we do.”

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