Tiny Tip: HOUSE as a discharge guide for marginalized patients that incorporates the social determinants of health

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Emergency Departments are often the primary source of healthcare for marginalized patients with substance use disorders and precarious housing​1​. As such, we have unique opportunities to intervene and initiate change. While many screening tools exist to identify substance use disorders, the novel H.O.U.S.E. mnemonic is the first to cover high yield items to be discussed with patients prior to discharge​2​. It can be used as an easy to remember tool to ensure that patients with complex social needs have been fully cared for and connections have been made to appropriate local resources.

HOUSE

Use the mnemonic HOUSE​3​ to help as a discharge guide for marginalized patients that incorporates the social determinants of health.

Housing precarity: Inquire about housing stability and identify the need for housing intervention.

Outcomes of mental illness: Investigate psychiatric history and any associated comorbidities including disability, substance use, or related medical illness.

Understanding income: Ask about finances and if there are challenges paying bills or buying food, especially nearing the end of month.  

Start case management for mental health: Liaise with local programs for further assessment and treatment including community mental health programs, psychiatric services, detox vs inpatient care programs or other specialist referral.

Evaluate substance use: Identify harmful patterns of substance use or the presence of addictions. Connect patients to addictions specialists or harm reduction programs.

References

  1. 1.
    Hawk K, D’Onofrio G. Emergency department screening and interventions for substance use disorders. Addict Sci Clin Pract. Published online August 6, 2018. doi:10.1186/s13722-018-0117-1
  2. 2.
    Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G. Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ. 2020;192(10):240. https://doi.org/10.1503/cmaj.190777
  3. 3.
    Mathies N, Saad A, Magwood O, Lee A, Tugwell P. The Fifth Vital Sign: ‘H.O.U.S.E,’ a practical medical mnemonic that puts ‘housing-first’ and includes social determinants of health for current and post-COVID-19 Emergency and Primary Health Care. Cochrane Equity Methods. Published online January 26, 2021.

Reviewing with the Staff

The COVID-19 pandemic has amplified housing, employment and income insecurity, substance use, discrimination and these issues are now accompanying patients to our Emergency Departments (ED). May front-line clinicians are already suffering provider burnout and other illnesses related to the COVID-19 pandemic and so there is an urgent need for efficient and evidence based approaches to address the needs of marginalized patients with complex social issues. Rapid effective care strategies increase a sense of professional autonomy and improve work satisfaction, and for this reason we present this practical tip from the new CMAJ homeless health guidelines (2020) to prevent negative outcomes from precarious housing and substance

We present the fifth vital sign for ER clinicians in the form of a medical mnemonic. The H.O.U.S.E. mnemonic reframes the ER approach to marginalized patient interactions, highlighting the importance of permanent housing, income interventions, and harm reduction strategies. Similar to the ACLS acronyms, H.O.U.S.E enables an evidence and needs-based empathic approach to prevent precarious housing within and ED that can alter life course trajectories. The ER might be the patient’s first and only point of contact with the healthcare system and similar to myocardial infarctions, we cannot let preventable illnesses slip through the cracks.

Kevin Pottie, MD, CCFP MClSc FCFP
Dr. Kevin Pottie is a professor of family medicine and epidemiology and community medicine and a clinical investigator at the Bruyere Research Institute, University of Ottawa. A former ER doc, his novel research methods bring evidence-based medicine to homeless, refugees and migrants and frail elderly populations.
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Nicole Mathies

Nicole Mathies

Nicole Mathies is a medical student at the University of Ottawa. Her academic interests include advocacy efforts in the areas of homelessness, HIV burdened communities, and microaggressions. She hopes to eventually combine her love for Emergency Medicine with Addictions Medicine and continue advocating for marginalized populations.