Pediatric Resident Education to Support Housing Security Among Hospitalized Children

The negative effects on child health from housing insecurity are well established.1–3 The impact of formal pediatric resident curricula exclusively dedicated to childhood housing insecurity on clinical practice remains unknown.4 We hypothesized that a resident curriculum on housing insecurity would be associated with increased frequency of (1) housing assessments and (2) referrals for housing assistance among hospitalized children.We compared the subsequent housing-related actions of 29 postgraduate year 1 (PGY1) residents (2020–2021 academic year) who completed a previously published childhood housing insecurity curriculum (see Supplemental Figure) with 28 PGY1 residents (2019–2020 academic year) who did not complete the curriculum.4 Both groups reported minimal prior educational or patient care experiences with housing insecurity, and there were no significant demographic differences between the resident groups.We reviewed the charts of patients on the hospital medicine service before and after curriculum implementation (fall 2019 through early summer 2020 and fall 2020 through early summer 2021, respectively). Each PGY1 resident rotated on this service several times at different points throughout the academic year. Since diagnostic codes for social risks are rarely used among hospitalized patients, we manually reviewed the charts.5 Based on the literature and an a priori power analysis using G*Power version 3.1.9.8 (Heinrich Heine University) to achieve 80% power at 0.05 significance level, we reviewed 20 admission notes performed by each PGY1 resident (560 charts for the comparison group and 580 charts for the intervention group) for assessments of housing (domains of housing stability, safety, quality, and affordability).6 No additional cases were identified following review of associated social work notes, discharge planning notes, and discharge summaries. Hospitalizations that had a strong correlation with placement or housing conditions (eg, abandonment, lead poisoning, asthma) were excluded since residents would be expected to directly evaluate patients’ housing circumstances.Data collection included patient’s age, admission season, number of parents and siblings, payer status, presence of and reasons for social work consultation, and assessment of housing. Descriptive statistics, Pearson correlation, and χ2 tests using SPSS version 28 (IBM Corporation) were performed to compare patient characteristics and housing-related behaviors of the resident groups. The study was approved by the institutional review board.Housing was evaluated in 2.5% (14/560) of the comparison group and 6.7% (39/580) of the intervention group (χ2 = 11.468, P < .001). Identification of housing problems by both groups resulted in referrals for housing assistance. There were no significant correlations between the assessment of housing and patient age (r = 0.002, P = .95), number of parents in the household (r = −0.046, P = .12), or hospitalization season (r = −0.025, P = .39) (Tables 1 and 2).A childhood housing insecurity curriculum was associated with an increase in resident assessments of housing and referrals for housing support among hospitalized children. Overall, charts describing any housing circumstances were limited, and there were no hardwired processes already in place to promote inquiry and documentation of housing. An automated screening tool, a prompt in the electronic medical record, or a note template with housing information could be the next step for system-level and sustainable practice. This standardization in conjunction with educating residents on housing insecurity could better reinforce the integration of this topic into patient care.Documented housing-related clinical practice was dependent on each resident’s actions, and this indicates the likelihood that our findings reflect the impact of the curriculum itself. This is further supported by the absence in recognized cases of insecure housing by the comparison group in contrast to the curriculum participants. Although the curriculum was the only housing-related education that existed in the residency program or hospital during the study period, we cannot exclude the possibility that participants were more mindful of the topic based on other experiences.As insecure housing and associated adverse health outcomes remain a pervasive problem nationwide, it is imperative to educate residents on this issue. It is essential to reframe the problem so that it is highlighted in all care settings, especially since children living in insecure housing conditions often receive fragmented health care, rely on acute care services, and experience more hospitalizations.2,7,8 This underscores the importance of hospital-based clinicians being equipped to advocate for equitable care and support the needs of children affected by housing insecurity.The authors would like to thank the Academic Pediatric Association’s Educational Scholars Program.