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In recent years, there has been growing recognition of the need for healthcare and healthcare systems to better understand and measure social and economic factors in an effort to adapt practices and care for patients.1,2 These factors, commonly described as social determinants of health, refer to aspects of the environments "in which people are born, live, learn, work, play, worship, and age" and have been linked to a number of health outcomes.3–6 These factors, and their upstream causes, may account for more of the variation in health and health outcomes than traditionally-examined aspects of the healthcare system.7–10 Housing is among the most fundamental social determinants of health, and persons who are homelessness are among the most socially and medically vulnerable populations.
Homelessness is a complex problem that is estimated to affect more than 550,000 Americans on any given night in the United States, including an estimated 23,000 persons experiencing homelessness in Cuyahoga County, Ohio in 2018.11–14 Homelessness and health influence one another through multiple, reinforcing mechanisms. For example, poor health can lead to employment problems which, in turn, affect one's ability to afford safe and reliable housing. Conversely, stress and the experience of homelessness may introduce or exacerbate health issues such as infectious disease, high blood pressure, diabetes, and asthma.15–19 Many authors have documented the extent to which mental health issues arise with homelessness, including incident and more severe episodes of alcoholism, anxiety, depression, and other psychiatric conditions.20 Less is known, however, about the extent to which this comorbidity burden can be captured using electronic health records as well as how this burden compares to groups of varying socioeconomic status and deprivation.
Multiple definitions of homelessness exist and the identification of persons experiencing homelessness presents an operationally challenging task within healthcare systems.14,21 This difficulty may partially explain why healthcare systems have had varied, and mostly limited, success in identifying and optimizing care for homeless individuals. We used a regional EMR registry to identify a population of persons experiencing homelessness who received care from either of two large health systems in Northeast Ohio—the Cleveland Clinic Health System and the MetroHealth System, the main campuses of which are located in Cuyahoga County. We then characterized...