Homelessness is a prevalent problem in American emergency departments, which serve as social safety nets for indigent and sick.

A new qualitative study of newly homeless emergency department patients found multiple contributing factors to homelessness. Now that the factors have been identified, they can impact ED-based homelessness prevention intervention.

The study was conducted at a New York City public hospital emergency department. English‐speaking patients 18 years or older with a new‐onset homelessness (defined as living in a shelter or on the streets) episode in the past six months were eligible.

"We chose this time frame because we felt that patients would be most likely to remember details about how and why they became homeless when it was a relatively recent experience," the study authors wrote.

Over a period of 13 months, 31 participants met the criteria and agreed to participate. Study participants were interviewed by an emergency department physician trained in qualitative research methods. Participants were primarily male, of mixed ethnicities and races and had a mean age of 50.

More than half of those surveyed reported job loss as the impetus for their homelessness. Despite having savings or the ability to live with or borrow money from friend and family, those interviewed were not able to find a job that allowed them to continue to pay for housing, hence their homeless status.

Health conditions were a common reason why survey participants lost their jobs. Substance abuse was another primary contributor to participants' homeless status.

"When asked what caused their homelessness, participants often stated initially the one or sometimes two most prominent or proximal causes of their homelessness. In listening to their stories, however, it was clear that for most people homelessness resulted from a series of several different factors," the study authors wrote.

Specifically, 23 participants identified structural factors like the cost of rent, difficulties with landlords, or employment challenges as contributing to their homeless status. Some identified personal choices as reasons for their lack of housing. For example, a man in his 60s said he chose to leave a nursing home because “I'm tired of sitting in there doing nothing all day.”

While some reported receiving assistance of some sort from family and friends, others said they didn't want to bother loved ones or those in their support network couldn't afford to provide assistance.

One unifying comment among participants was a surprise at their homeless state. In fact, when each was asked directly what might have prevented their homelessness, most couldn't answer.

This observation speaks to the benefit of universal homelessness risk screening in the ED rather than expecting patients to self‐identify a need for social service referrals. Also, since health conditions often strongly influenced homelessness, health systems should seek out collaborative partnerships to address homelessness.

"This fascinating qualitative study demonstrates that listening carefully to our patient's needs will allow us to discern social determinants that left unattended may lead to homelessness. Our task in the emergency department is to presume that each patient who comes to our doors is there because of a critical lesion in the public health system. In addressing these lesions, we will begin to achieve our dreams of preventing homelessness," the study authors wrote.