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Table.  
Characteristics of Patients With vs Without Housing Problems Among Patients at US Community Health Centers
Characteristics of Patients With vs Without Housing Problems Among Patients at US Community Health Centers
1.
Health Resources and Services Administration.  2016 Health center data. https://bphc.hrsa.gov/uds/datacenter.aspx. Accessed November 1, 2017.
2.
Health Resources and Services Administration.  Health Center Patient Survey. https://bphc.hrsa.gov/datareporting/research/hcpsurvey/index.html. Accessed November 2, 2017.
3.
National Health Care for the Homeless Council.  What is the official definition of homelessness?https://www.nhchc.org/faq/official-definition-homelessness/. Accessed August 22, 2017.
4.
Montgomery  AE, Fargo  JD, Kane  V, Culhane  DP.  Development and validation of an instrument to assess imminent risk of homelessness among veterans.  Public Health Rep. 2014;129(5):428-436.PubMedGoogle ScholarCrossref
5.
Kushel  MB, Gupta  R, Gee  L, Haas  JS.  Housing instability and food insecurity as barriers to health care among low-income Americans.  J Gen Intern Med. 2006;21(1):71-77.PubMedGoogle ScholarCrossref
6.
National Alliance to End Homelessness.  The state of homelessness in America. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report/. Accessed November 15, 2017.
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Research Letter
February 20, 2018

Prevalence of Housing Problems Among Community Health Center Patients

Author Affiliations
  • 1Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 2Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill
  • 3Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston
  • 4Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
JAMA. 2018;319(7):717-719. doi:10.1001/jama.2017.19869

In 2016, the Health Resources and Services Administration (HRSA) Health Center Program provided primary care to more than 25 million medically underserved patients through a nationwide network of community health center (CHC), health care for the homeless, migrant health center, and public housing primary care clinics.1 Although the latter 3 clinic types serve individuals with housing problems by definition, little is known about the scope of housing problems among CHC patients, who constitute 91% of Health Center Program patients nationally.1 We used data from a national survey to assess the prevalence and health-related correlates of housing problems among CHC patients.

Methods

The Partners Human Research Committee exempted this study. We analyzed the 2014 Health Center Patient Survey, a nationally representative, cross-sectional, in-person survey of Health Center Program patients conducted by RTI International from September 2014 through April 2015 using a 3-stage sampling design.2 First-stage sampling units were Health Center Program grantees, stratified by funding stream, substratified by other characteristics, and sampled with probability proportional to size. Second-stage sampling units were clinic sites within grantees. Third-stage sampling units were patients sampled consecutively at clinics if they had made 1 prior visit or more within the past year; 91.4% of those eligible completed interviews. We confined our analysis to CHC patients aged 18 years or older.

We used responses to items assessing living circumstances to create 5 mutually exclusive housing categories: (1) homeless—usually slept during the past week in an emergency shelter, transitional shelter, or car; anywhere outside; or any other place not meant for habitation; (2) doubled-up—past-week residence in a house, apartment, or room that they did not rent or own (doubled-up individuals are considered homeless by HRSA but not by the US Department of Housing and Urban Development3); (3) unstably housed—past-week residence in their own place but moved 2 or more times in the past year4 or was unable to pay the rent or mortgage at any time;5 (4) stably housed, previously homeless—past-week residence in their own place without the above difficulties but previously homeless, reflecting potential housing risk;4 and (5) stably housed, never homeless—no current or prior housing problems.

Other variables included self-reported demographic characteristics, health status indicators, and measures of health care use and access, each defined in the Table.

We used Rao-Scott χ2 tests with a 2-sided P value of less than .05 for significance to compare respondents with (categories 1-4) vs without (category 5) current or prior housing problems. We examined whether those with housing problems had ever received CHC assistance in finding a place to live. We conducted analyses in SAS (SAS Institute), version 9.4, using strata, cluster, and weight variables to account for the sampling design. Reported percentages are weighted.

Results

Of 3172 adult CHC patients, 3148 provided sufficient information to characterize their housing status. Of these, 1.2% (95% CI, 0.6%-1.8%) reported current homelessness, 9.0% (95% CI, 6.8%-11.2%) reported doubling-up, 26.8% (95% CI, 23.1%-30.6%) reported unstable housing, and 6.5% (95% CI, 4.6%-8.5%) reported stable housing but previous homelessness, totaling 43.6% (95% CI, 39.0%-48.1%) with any history of housing problems. Compared with those without housing problems, participants with housing problems were more likely to report health problems, emergency department use, and delays in care (Table). Twenty-nine percent (95% CI, 4.4%-52.9%) of homeless, 1.1% (95% CI, 0%-2.2%) of doubled-up, and 2.5% (95% CI, 0.8%-4.2%) of unstably housed patients reported CHC assistance in finding a place to live.

Discussion

In this cross-sectional study, 43.6% of adult CHC patients reported housing problems, including 1.2% who reported current homelessness. By comparison, the point prevalence of homelessness in the US population has been estimated at 0.18%.6 Limitations of this study include reliance on cross-sectional self-report, the lack of a validated measure of housing instability, and the potential lack of generalizability to non-CHC clinic settings. Additionally, we did not examine the correlates of specific housing problems. Nonetheless, the high prevalence of housing problems and their association with adverse health metrics suggests that CHCs should consider universal screening of housing status.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: November 28, 2017.

Corresponding Author: Travis P. Baggett, MD, MPH, Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (tbaggett@mgh.harvard.edu).

Author Contributions: Dr Baggett had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Baggett.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Baggett.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Baggett, Berkowitz, Fung.

Obtained funding: Baggett.

Administrative, technical, or material support: Baggett.

Supervision: Baggett.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Baggett reported receiving royalty payments from UpToDate for authorship of a topic review on the health care of homeless people in the United States. No other disclosures are reported.

Funding/Support: This study was supported by grants K23DA034008 from the National Institute on Drug Abuse (Dr Baggett), K23DK109200 from the National Institute of Diabetes and Digestive and Kidney Diseases (Dr Berkowitz), R01HS025378 from the Agency for Healthcare Research and Quality (Dr Fung), and by the Massachusetts General Hospital Department of Medicine Transformative Scholars Program (Baggett).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The study content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Agency for Healthcare Research and Quality, or Massachusetts General Hospital.

References
1.
Health Resources and Services Administration.  2016 Health center data. https://bphc.hrsa.gov/uds/datacenter.aspx. Accessed November 1, 2017.
2.
Health Resources and Services Administration.  Health Center Patient Survey. https://bphc.hrsa.gov/datareporting/research/hcpsurvey/index.html. Accessed November 2, 2017.
3.
National Health Care for the Homeless Council.  What is the official definition of homelessness?https://www.nhchc.org/faq/official-definition-homelessness/. Accessed August 22, 2017.
4.
Montgomery  AE, Fargo  JD, Kane  V, Culhane  DP.  Development and validation of an instrument to assess imminent risk of homelessness among veterans.  Public Health Rep. 2014;129(5):428-436.PubMedGoogle ScholarCrossref
5.
Kushel  MB, Gupta  R, Gee  L, Haas  JS.  Housing instability and food insecurity as barriers to health care among low-income Americans.  J Gen Intern Med. 2006;21(1):71-77.PubMedGoogle ScholarCrossref
6.
National Alliance to End Homelessness.  The state of homelessness in America. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report/. Accessed November 15, 2017.
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