Exploring Patterns of Emergency Department Use for People Experiencing Homelessness in New Brunswick

Abstract

Background: Homelessness is a complex and growing issue that negatively affects both individuals and communities. People experiencing homelessness (PEH) often have high levels of unmet health care needs resulting from higher risk of poor health and greater challenges in accessing appropriate health care than the general population. In Atlantic Canada, housing prices are rapidly increasing, reducing housing affordability and accessibility. These population-level factors may play a role in the health of PEH.

Objectives: 1) Among individuals with visits to the Emergency Department at Horizon Health, identify PEH and people not experiencing homelessness (“controls”) and describe their demographics, reasons for using the ED, triage level, number of ED visits, and whether they have a primary care provider; 2) To compare ED use among PEH and controls to determine whether there is a difference in the total number of visits, triage level, and whether they have a primary care provider; 3) To determine whether changing housing prices are associated with differences in ED presentation (number of visits and/or reasons) for PEH and controls between 2020 and 2024 across three cities (Fredericton, Moncton, and Saint John).

Methods: A repeated cross-sectional study was conducted using administrative health data from four hospitals across three NB cities. Patients were defined as homeless if they were identified as experiencing homelessness in their record or give the address of a shelter or hotel. Nearest neighbour propensity score matching was used to establish a comparable control group, matching patients on facility, sex, and age. Generalized linear models (GLM) were used to assess the effect of experiencing homelessness on the total number of visits (Poisson), average triage level (linear), and primary care provider status (logistic) of PEH and matched controls. Rental price and vacancy rates were graphed by city and year, and correlation coefficients are estimated against ED visits.

Results: Between 2020 and 2024, there were 810 PEH and 226,729 housed individuals who presented to the ED. Compared to matched controls, the rate of ED use for PEH was 1.55 times greater for PEH than matched controls (IRR = 1.55, CI: [1.45, 1.66], p < 0.001). Mental health presentations were four times more common among PEH (18.5%) than among controls (4.7%). PEH have 57.7% lower odds of having a primary care provider compared to controls (OR = 0.42, CI: [0.34, 0.52], p < 0.001). PEH had an average 0.11 point lower average CTAS score (coef. = -0.11, CI: [-0.18, -0.03], p = 0.004). ED visits by PEH increased in all cities over the study period, with a particularly sharp rise in Saint John. Rental prices also increased and correlated positively between ED visits by PEH and lowest quartile rental prices (r = 0.36 for one-bedroom units), and negatively with vacancy rate (r = -0.27).

Conclusion: This study provides one of the first population-level analyses of ED use among PEH in NB. PEH have higher ED utilization, more acute presentations, and lower access to primary care compared to housed individuals. Patterns of ED use appeared to reflect broader trends in housing affordability, highlighting the need for coordinated housing and healthcare policy interventions.