Better quality hospital data for identifying patients experiencing homelessness

Health care needs of patients experiencing homelessness

PEH are likely to face physical, mental and social challenges that contribute to poor health. These challenges include harsh living conditions, victimization and discrimination.Reference3 This group has a high level of need for health services to treat acute and chronic conditions.Reference3 Reference4 PEH rely more on hospital services than the general population, in part due to barriers to accessing primary care.Reference4 Reference5 When discharged from a hospital to the community, they also experience more difficulty managing their health conditions. Discharge planning is essential to assist PEH to obtain local services and supports such as housing, food, transportation and medical supports.

Mandatory recording of homelessness

In 2018–2019, it became mandatory for hospital coders to assign ICD-10-CA code Z59.0 Homelessness when the patient’s record showed they were homeless upon admission. As described in the Canadian Coding Standards, the requirement applied to abstracts submitted to the Discharge Abstract Database (DAD) and the National Ambulatory Care Reporting System (NACRS). At the same time, the ministère de la Santé et des Services sociaux du Québec issued a coding requirement for Z59.0, not limited to homelessness at the time of admission. As a result, coding Z59.0 was mandatory for all facilities included in the Hospital Morbidity Database (HMDB) as of April 2018. In 2022–2023, the requirement in the Canadian Coding Standards changed to “whenever homelessness was documented, during an episode of care.”Reference6

Increased recording of homelessness in hospital data

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 Z59.0), compared with the previous year. For more information, see the figure on this page in the section Trend in hospitalizations with recorded homelessness. Analysis of ED visits (not shown) also revealed a substantial increase in records that included Z59.0, starting in 2018–2019.

Opportunities to improve consistency in recording homelessness

Through stakeholder engagement, we heard about some of the challenges associated with 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 coders may not have sufficient time allocated to review all parts of the patient record where housing status may be documented (e.g., in notes by allied health professionals).

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.Reference7 Implementing a screening tool that covers social determinants of health 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 and raise awareness of its value for planning and improving services.

Data that consistently identifies PEH in hospital information systems can be used to inform improvements in quality, experience and coordination of care. Many stakeholders play a role in the process — from asking a patient about their housing status to reporting on findings to guide improvements.

ICD-10-CA (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada) is a national standard maintained by CIHI. It classifies diseases, injuries and causes of death, as well as external causes of injury and poisoning. The ICD-10-CA classification includes a range of codes (Z55–Z65) that correspond to social determinants of health. These Z-codes can be used to record a patient’s social needs and socio-economic circumstances, including problems related to housing, employment, poverty, social environment and legal circumstances.Reference8

Collecting ICD-10-CA Z-codes more routinely in patients’ records would generate valuable information for clinicians who treat the patient and for secondary analysis to inform system improvements. National organizations in the United States, including the American Hospital Association (AHA), encourage greater use of social determinants of health Z-codes to support quality improvement and have published guidance to support their adoption.Reference9 Reference10 To facilitate adoption, the AHA recommended that coders use the documentation of social needs by any staff person who met the requirements to add information to the patient’s medical record. As such, the documentation available to coders would include that from non-physician providers (e.g., social workers, community health workers, case managers, nurses).Reference9

• Homelessness and hospital use
• Codes, Classifications, and Terminologies
• Homelessness — Tip for Coders (PDF)
• Discharge Abstract Database
• Hospital Morbidity Database
• National Ambulatory Care Reporting System
• Health equity and population health

CIHI’s Population Health department

Send us an email:
populationhealth@cihi.ca