Cross-sectional characterisation of housing and social service engagement prior to death among adults experiencing homelessness in Harris County, Texas, USA

Introduction People experiencing homelessness are at disproportionate risk of premature mortality. In Harris County, Texas, USA, mortality has continued to rise despite reductions in unsheltered homelessness. The extent and timing of housing and social service engagement preceding these deaths remain poorly understood yet may help inform whether and how service engagement could play a role in prevention. Methods This cross-sectional study included 417 adults who died while experiencing homelessness in Harris County between January 2021 and December 2022. Medical examiner records were probabilistically linked to the regional Homeless Management Information System (HMIS) to assess service engagement from January 2020 until death. Bivariate analyses compared decedents with and without HMIS records and among those in HMIS, individuals with and without recent service interactions (≤12 months before death). Results The median age at death was 55 years. Just over half of decedents (53.48%) had an HMIS record but only 29.50% had a recent service interaction. The most frequently documented services were basic needs provision and case management while street outreach engaged the largest number of individuals. Significant racial and ethnic differences were observed, with Hispanic and non-Hispanic Asian decedents less likely to have used services compared with non-Hispanic Black and non-Hispanic White decedents. Conclusion Nearly half of those who died while experiencing homelessness had no documented service record, and fewer than one-third had any recent engagement, highlighting limited connection with services prior to death. Strengthening continuity and frequency of contact, expanding culturally responsive outreach and enhancing pathways to housing-focused services may support improved engagement and risk identification, though their implications for mortality require further investigation.