Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults: A Randomized Trial

Collaborative Research Unit, Department of Medicine, Stroger Hospital of Cook County, 1900 W Polk St, Room 1606, Chicago, IL 60612, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 06/2009; 301(17):1771-8. DOI: 10.1001/jama.2009.561
Source: PubMed

ABSTRACT Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services.
To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses.
Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat.
Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers.
Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors.
The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], -1.2 to 0.2), 2.7 fewer hospital days (95% CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, -2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%).
After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care. Identifier: NCT00490581.

  • Source
    • "Indeed, this study may be a world-first. While there has been a number of important studies in both the United States and the United Kingdom employing large samples, they all focus exclusively on relatively narrow population sub-groups, such as people who access publicly funded shelters (for example, Culhane and Kuhn 1998), homeless young people (Craig et al. 1996) or homeless people who are chronically ill (Sadowski et al. 2009). To our knowledge, there has only been one other large-scale longitudinal study that includes both people at risk of homelessness and people currently experiencing homelessness (Shinn et al. 1998) and even that is restricted to residents in one city. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Homelessness, despite being a major social policy issue in Australia, is an area that is not well served by data. Most sorely lacking is any large‐scale panel study that follows a broad sample of persons with recent experience of homelessness and unstable housing histories. In 2010, the Australian Government set about rectifying this deficiency when it commissioned the Melbourne Institute to undertake a new panel study, now known as ‘Journeys Home’. This study draws its sample from the population of Centrelink income‐support recipients, targeting persons identified in the administrative data as having recent experience of homelessness, as well as others with similar characteristics who may be vulnerable to housing difficulties in the future. This article summarises the design of this new study and reports on fieldwork outcomes from the first two waves of data collection.
    Australian Economic Review 09/2012; 45(3). DOI:10.1111/j.1467-8462.2012.00690.x · 0.27 Impact Factor
  • Source
    • "Two usual care participants withdrew their consent after randomization. See original paper for further details (Sadowski et al. 2009). Baseline characteristics between the two study groups were similar except that more intervention participants had been hospitalized at the two Homeless patients referred from hospital social workers and assessed for eligibility "
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess the costs of a housing and case management program in a novel sample-homeless adults with chronic medical illnesses. The study used data from multiple sources: (1) electronic medical records for hospital, emergency room, and ambulatory medical and mental health visits; (2) institutional and regional databases for days in respite centers, jails, or prisons; and (3) interviews for days in nursing homes, shelters, substance abuse treatment centers, and case manager visits. Total costs were estimated using unit costs for each service. Randomized controlled trial of 407 homeless adults with chronic medical illnesses enrolled at two hospitals in Chicago, Illinois, and followed for 18 months. Compared to usual care, the intervention group generated an average annual cost savings of (-)$6,307 per person (95 percent CI: -16,616, 4,002; p = .23). Subgroup analyses of chronically homeless and those with HIV showed higher per person, annual cost savings of (-)$9,809 and (-)$6,622, respectively. Results were robust to sensitivity analysis using unit costs. The findings of this comprehensive, comparative cost analyses demonstrated an important average annual savings, though in this underpowered study these savings did not achieve statistical significance.
    Health Services Research 11/2011; 47(1 Pt 2):523-43. DOI:10.1111/j.1475-6773.2011.01350.x · 2.49 Impact Factor
  • Source
    • "Other difficult-to-replicate therapies in samples of mild to moderately depressed patients have also shown some effectiveness; for instance, a mild to moderately depressed sample showed improvement with animal (dolphin)-facilitated therapy in Honduras (Antonioli & Reveley, 2005). The concept that contextual interventions may improve health outcomes more generally is bolstered further by recent studies from Chicago and Seattle looking at the provision of housing for chronically ill homeless adults (Larimer et al., 2009; Sadowski et al., 2009), although no mental health outcomes were included in either study. Future work should explore the differences between using contextual interventions as treatment for depressed patients in primary care or other treatment settings, and in ethnicity-and language-specific populations, versus using them for prevention in community-wide samples. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Numerous observational studies demonstrate associations between social context and depressive symptoms, yet few intervention trials exist in this arena. This review examines intervention trials that explore the impact of contextual change on depressive symptoms. Electronic literature databases of PubMed and PsycINFO, bibliographies of retrieved articles and the publicly available internet were searched for English-language articles published between 1997 and 2008. Peer-reviewed studies were eligible for inclusion if they reported contextual interventions and depressive symptoms measures in adult populations without other significant underlying medical or psychological illness. In total, 2,128 studies met search term criteria. Of these, 13 studies meeting inclusion criteria were classified by type of intervention. Qualitative synthesis was used to interpret the mental health impact of contextual interventions. The interventions focused on employment, housing, poverty, parenting and violence. Eight of these studies reported a decrease in depressive symptoms and/or psychological distress in intervention groups. Interventions varied in focus, length of follow-up and measures of depressive symptoms. Contextual interventions for the prevention and treatment of depressive symptoms and psychological distress can be effective, though very limited data exist in this field. Policy implications include a greater emphasis on improving context to decrease depression and other mental disorders.
    International Journal of Social Psychiatry 03/2010; 57(4):402-17. DOI:10.1177/0020764010362863 · 1.15 Impact Factor
Show more


Available from