Use of a Community Center Primary Care Clinic and Subsequent Emergency Department Visits Among Unhoused Women

In the United States, the frequent amalgamation of homelessness, drug use, and exchange of sex for money, shelter, food, or drugs increases the risk of serious health conditions, including trauma and HIV.¹ Women who are unhoused have an all-cause mortality 5 to 8 times higher than housed women.² Seattle, Washington, is facing a housing crisis, with a 31% increase in homelessness from 2008 to 2018³ and a growing epidemic of opioid and methamphetamine use. In 2018, these overlapping epidemics created the context for an HIV outbreak in Seattle among unhoused heterosexual people.⁴

Several US cities have created mobile health clinics in an effort to engage unhoused people in medical care.⁵ In July 2018, the Safe, Healthy, Empowered (SHE) Clinic was founded to provide care for unhoused women colocated at Aurora Commons, a drop-in community center with a long-standing relationship with unhoused people in Seattle. Patients at the SHE Clinic reflect the unhoused population’s high rates of injection drug use, exchange sex, unplanned pregnancy, and sexually transmitted infections.⁶ In this cohort study, we evaluated the association between use of the SHE Clinic and the frequency of nonemergent emergency department (ED) visits among women living unhoused who exchange sex and inject drugs.

Survey data collected from an observational cohort of 76 women 18 years or older at Aurora Commons included self-identified demographic characteristics, fertility desires, and HIV risk factors. Participants provided oral and written consent for surveys and abstraction of electronic medical record data. REDCap (Research Electronic Data Capture software (Vanderbilt University) was used for survey collection and consenting participants. This study received ethical approval from the University of Washington Institutional Review Board. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

The SHE Clinic operates 4 hours a week and provides walk-in care. Participants with at least 1 visit to the SHE Clinic before February 2, 2019, were compared with participants with no visits. A manual review of participants’ electronic medical records from February 1, 2018, through August 1, 2019, was conducted to find the dates and chief concerns for ED visits in the Seattle area (10 facilities, 91% of the area EDs). Two clinician investigators (J.S. and M.L.G.) classified each ED visit as emergent or nonemergent. Emergency department visits for sexual assault, trauma, drug overdose, mental health crisis, or illness resulting in hospitalization were classified as emergent visits. Descriptive data analyses were performed with Stata version 15.0 software (StataCorp). Emergency department visit rates were calculated per woman per month, and paired Wilcoxon signed rank tests were used to compare the frequency of ED visits in the 6 months before and after a woman’s first SHE Clinic visit or a midperiod reference date for nonadopters.

A total of 76 cisgender women completed surveys. The median age of respondents was 37 years (interquartile range, 30-43 years). Forty-four women (58%) reported injection drug use in the past 3 months. Fifty-one women (67%) reported prior sexually transmitted infections. Forty-six women (60%) were tested for both Chlamydia trachomatis and Neisseria gonorrhoeae, and 40 women (53%) were tested for Trichomonas vaginalis; of these, 6 women (15%) had positive test results for C trachomatis, 5 (11%) for N gonorrhoeae, and 19 (48%) for T vaginalis. Four SHE Clinic patients were infected with HIV. Eligibility for HIV pre-exposure prophylaxis among women without HIV was high—76% (n = 55)—due to participation in transactional sex (n = 41), diagnosis of sexually transmitted infections (n = 25), and use of injection drugs (n = 44). Most women (67 [88%]) reported actively not wanting to become pregnant. Of the 48 women who were currently trying to avoid pregnancy (excluding 12 women with known infertility), only 8 women (17%) used contraceptives (Table). Forty-one women (54%) had established care at the SHE clinic.

Most women (67 [88%]) visited an ED during the 18-month study period and commonly had more than 3 ED visits (46 [61%]). Of the 388 ED visits by respondents, 168 (43%) were for emergent concerns, and 220 (57%) were for nonemergent concerns, such as isolated infections or a chronic condition. The frequency of visits for nonemergent concerns decreased among SHE Clinic patients from 37 visits in the 6-month pre-intervention period (mean, 0.50 visits per 100 woman-days; 95% CI, 0.32-0.68 visits per 100 woman-days) to 22 visits in the 6 months thereafter (mean, 0.30 visits per 100 woman-days; 95% CI, 0.15-0.45 visits per 100 woman-days) (P = .02). No change in the frequency of nonemergent visits was observed among nonadopters: 37 visits in the pre-intervention period (mean, 0.59 visits per 100 woman-days; 95% CI, 0.33-0.85 visits per 100 woman-days) vs 38 visits after the intervention (mean, 0.60 visits per 100 woman-days; 95% CI, 0.28-0.92 visits per 100 woman-days) (P = .51).

This was an observational study of real-life medical care use and has some limitations, including room for sampling bias because of the small sample size. Nevertheless, this study’s findings suggest that use of colocated clinic services may be associated with reduced nonemergent ED visits among unhoused women in Seattle, indicating the need for walk-in harm-reduction services.

Accepted for Publication: February 3, 2021.

Published: March 25, 2021. doi:10.1001/jamanetworkopen.2021.3134

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stewart J et al. JAMA Network Open.

Corresponding Author: Jenell Stewart, DO, MPH, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 Ninth Ave, Box 359931, Seattle, WA 98104 (jenells@uw.edu).

Author Contributions: Dr Stewart 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: Stewart, Dhanireddy.

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

Drafting of the manuscript: Stewart, Davidson, Dhanireddy.

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

Statistical analysis: Stewart, Ásbjörnsdóttir.

Obtained funding: Davidson.

Administrative, technical, or material support: Stewart, Stadeli, Green, Davidson.

Supervision: Stewart, Dhanireddy.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Stewart was supported by grants T32AI007044 and K23MH124466 from the National Institutes of Health (NIH), and Dr Stadeli was supported by training grant T32DK070555 from the NIH. The use of REDCap (Research Electronic Data Capture) software (Vanderbilt University) was supported by grants UL1TR002319, KL2TR002317, and TL1TR002318 from the Institute of Translational Health Science and from the National Center for Advancing Translational Sciences/NIH. The Safe. Healthy. Empowered (SHE) Clinic pilot program was supported by grants from Lahai Health for the period of April 1, 2018 through March 31, 2019, and by the City of Seattle Human Services Department. A mobile van owned and operated by Puget Sound Christian Clinic was used in the study.

Role of the Funder/Sponsor: The funding sources 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.

Additional Contributions: We thank the community at Aurora Commons, their volunteers, and staff. We also thank Monica Brown, RN, and Sherice Arnold, LICSW (Harborview Medical Center, University of Washington), who contributed operational and clinical support, and Matthew R. Golden, MD, MPH (Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington and Public Health—Seattle and King County), who assisted in an advisory capacity. No additional compensation was provided.