Screening for Housing Instability: Providers’ Reflections on Addressing a Social Determinant of Health
- 1 Downloads
The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services.
This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient’s housing status impacts clinical decision-making.
We conducted a qualitative study using in-depth semi-structured interviewing.
Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016.
Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients’ housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach.
Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients’ overall health and described how they factored patients’ housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening.
Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.
KEY WORDShomelessness social determinants of health screening qualitative research Veterans
This work was supported by the US Department of Veterans Affairs, Health Services Research and Development under Grant IIR-13-334 (Montgomery).
Compliance with Ethical Standards
The study was conducted at the Corporal Michael J. Crescenz VA Medical Center (CMCVAMC) in Philadelphia, PA, or an associated community-based outpatient clinic (CBOC), and was approved by the CMCVAMC Institutional Review Board.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
The views expressed here do not necessarily reflect those of the Department of Veterans Affairs or the United States Government.
- 4.Daniel H, SS B, GC K, Physicians for the H and PPC of the AC of. Addressing social determinants to improve patient care and promote health equity: An american college of physicians position paper. Ann Intern Med 2018;168(8):577–578.Google Scholar
- 12.O’Toole TP, Pape L. Innovative efforts to address homelessness among veterans. N C Med J 2015;76(5):311–314.Google Scholar
- 17.Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Vol 10.; 2006. doi: https://doi.org/10.1016/j.lisr.2007.11.003.
- 18.King N. Template analysis. Qualitative methods and analysis in organizational research: A practical guide. . In: Qualitative Methods and Analysis in Organizational Research: A Practical Guide. ; 1998:118–134.Google Scholar
- 20.Hwang SW. Homelessness and health. Cmaj. 2001;164(2):229–233.Google Scholar
- 23.USPSTF A and B Recommendations. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. Accessed August 12, 2017.