A Pragmatic Randomized Trial Integrating Homelessness Diversion Services into an Emergency Department Discharge System

Project Summary/Abstract The COVID-19 pandemic has shined a spotlight on the long-standing problem of homelessness in the U.S., a major public health concern since homelessness is both a cause and contributor to poor mental and physical health. Rising income inequality and disparate access to services/resources among vulnerable populations has been exacerbated by the pandemic which has resulted in a large population of people who are at-risk of becoming homeless. Primary prevention efforts are required to eliminate homelessness but the science of homelessness prevention is limited with no known scientifically rigorous trials testing the impact of homelessness diversion as an intervention for health and housing. Emergency departments (ED) provide an opportune space to target homeless diversion efforts to maximize the reach to individuals with elevated health and housing needs. Our long-term goal is to inform the knowledge base about homelessness diversion, including understanding whether embedding a homeless diversion program within a hospital ED discharge system has health and wellness benefits for the recipients (individuals) and the organizations who serve them (community). Guided by preliminary work and data, this goal will be accomplished through three specific aims to: 1) Determine whether a homelessness diversion program integrated into a hospital ED discharge system will lower ED use via increased housing retention and wellbeing. Our hypothesis is that relative to individuals receiving standard care, individuals who receive homelessness diversion services will have lower emergency department use via increased housing retention and health-related quality of life. Our approach to testing the working hypothesis will be to perform a pragmatic single-blind randomized trial with 1,000 individuals exiting the ED and analyze outcomes over six months. 2) Determine characteristics of individuals most likely to benefit from homelessness diversion. Our approach will be to conduct secondary analyses of data from our randomized trial to identify sociodemographic and clinical factors related to outcomes from homeless diversion services. 3. Discover opportunities to tailor homeless diversion services to better meet the needs of diverse communities. We will conduct surveys and focus groups with 40 diverse homeless diversion clients followed by consideration of key stakeholders. The findings from this project will provide critical information on the most effective strategies for diverting individuals at imminent risk for homelessness, providing an upstream intervention to addressing health inequities among this vulnerable population.