A patient’s housing status impacts not only their health outcomes, but where and how they access health care and manage chronic conditions. People experiencing homelessness (PEH) have a high level of need for health care services due in part to the higher incidence of physical, mental and social challenges. They rely more on hospital services than the general public.
The Canadian Institute for Health Information (CIHI) along with key stakeholders identified an opportunity to improve the identification of PEH when they access hospital services. Better data on services used by this group of patients can facilitate improvements in their care, as well as health system planning that responds to their care needs.
As of 2018-2019, it became mandatory for hospitals to include ICD-10-CA code Z59.0 Homelessness in their data when the patient’s record showed they were homeless upon admission. ICD-10-CA (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada) is a national standard maintained by CIHI.
CIHI released a report in July 2023 on trends in documenting the Z59.0 code over a 6-year period. The report also describes the important roles that different health system stakeholders have in creating and using quality data to improve outcomes for PEH – from asking a patient about their housing status to assigning ICD-10-CA codes in the data to reporting on findings to guide improvements.
“With more consistent use of the ICD code, Z59.0, there’s a genuine opportunity to get better data to fully understand the unique needs of this population. But hospital coders who assign the code can only use it if homelessness is noted in the patient record, and at present housing status is not consistently gathered during patient registration or health care encounters,”says Keith Denny, Director of Population and Indigenous Health, and Classifications and Terminologies, CIHI.
Increased recording of homelessness
Mandatory use of code Z59.0 Homelessness represented a step in improving care for PEH in Canada. The first year the requirement was in effect (2018–2019), there was an 84% increase in the number of hospitalizations in Canada with recorded homelessness using the code, compared with the previous year. More information can be found in the figure “Trends in hospitalizations with recorded homelessness”.
Opportunities to improve consistency
Challenges remain for comprehensively recording homelessness. For example, some patients may not identify themselves as experiencing homelessness due to a concern about stigma or for other reasons. Another limitation is that hospital information management staff may not have sufficient time allocated to review all parts of the patient record where housing status may be documented.
To further improve data quality, hospital leaders could consider implementing formal procedures to ensure that health care providers ask about and document housing status – something that will be required by 2024 of all United States hospitals that report to the Centers for Medicare & Medicaid Services’ quality reporting program. Implementing a patient screening tool that covers social needs is one way to support consistent identification of PEH. Hospital leaders could also support staff to build their skills for assessing patients’ social needs, including housing, in safe and appropriate ways. In addition, they could use data on recorded homelessness at the organization level to plan and improve services such as discharge supports. Organizations such as regional authorities can also leverage the data collected in the hospital setting to inform initiatives to improve care and outcomes for PEH.
Please visit https://www.cihi.ca/en/better-quality-hospital-data-for-identifying-patients-experiencing-homelessness for additional information on patients experiencing homelessness.