Hospitalization Costs Associated With Homelessness in New York City

Department of Family Medicine, University of Iowa, Iowa City, Iowa, United States
New England Journal of Medicine (Impact Factor: 55.87). 07/1998; 338(24):1734-40. DOI: 10.1056/NEJM199806113382406
Source: PubMed


Homelessness is believed to be a cause of health problems and high medical costs, but data supporting this association have been difficult to obtain. We compared lengths of stay and reasons for hospital admission among homeless and other low-income persons in New York City to estimate the hospitalization costs associated with homelessness.
We obtained hospital-discharge data on 18,864 admissions of homeless adults to New York City's public general hospitals (excluding admissions for childbirth) and 383,986 nonmaternity admissions of other low-income adults to all general hospitals in New York City during 1992 and 1993. The differences in length of stay were adjusted for diagnosis-related group, principal diagnosis, selected coexisting illnesses, and demographic characteristics.
Of the admissions of homeless people, 51.5 percent were for treatment of substance abuse or mental illness, as compared with 22.8 percent for the other low-income patients, and another 19.7 percent of the admissions of homeless people were for trauma, respiratory disorders, skin disorders, and infectious diseases (excluding the acquired immunodeficiency syndrome [AIDS]), many of which are potentially preventable medical conditions. For the homeless, 80.6 percent of the admissions involved either a principal or a secondary diagnosis of substance abuse or mental illness -- roughly twice the rates for the other patients. The homeless patients stayed 4.1 days, or 36 percent, longer per admission on average than the other patients, even after adjustments were made for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The costs of the additional days per discharge averaged $4,094 for psychiatric patients, $3,370 for patients with AIDS, and $2,414 for all types of patients.
Homelessness is associated with substantial excess costs per hospital stay in New York City. Decisions to fund housing and supportive services for the homeless should take into account the potential of these services to reduce the high costs of hospitalization in this population.

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    • "Chronically ill, homeless people experience poor health and adverse outcomes at a higher rate than the general population, resulting in elevated morbidity and mortality with a life expectancy about 30 years less than the US average[1]–[3] The health decline of chronically ill, homeless people is often accompanied by high rates of emergency department visits and hospitalizations, often preventable, which combined with poor use of primary care, results in costly and inefficient use of health care system resources.[4]–[15]. "
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    ABSTRACT: Case management programs for chronically ill, homeless people improve health and resource utilization by linking patients with case managers focused on improving management of medical and psychosocial problems. Little is known about participants' perspectives on case management interventions. This qualitative study used in-depth, one-on-one interviews to understand the impact of a case management program from the perspective of participants. A standardized interview guide with open-ended questions explored experiences with the case management program and feelings about readiness to leave the program. FOUR RECURRENT THEMES EMERGED: (1) Participants described profound social isolation prior to case management program enrollment; (2) Participants perceived that caring personal relationships with case managers were key to the program; (3) Participants valued assistance with navigating medical and social systems; and (4) Participants perceived that their health improved through both the interpersonal and the practical aspects of case management. Chronically ill, homeless people enrolled in a case management program perceived that social support from case managers resulted in improved health. Programs for this population should consider explicitly including comprehensive social support interventions. Further research on case management should explore the impact of different types of social support on outcomes for homeless chronically ill patients.
    Full-text · Article · Sep 2012 · PLoS ONE
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    • "During the preparation of our systematic review [4], we found only two studies which examined such factors among the 106 that we screened in full for inclusion (see below); similarly, housing-related factors were neither examined in previous high-quality studies of LOS in England [5,6], Germany [7] and Scandinavia [8], nor in case–control studies of long-stay versus typical length admissions performed in the US [9] and in Switzerland [10,11]. Studies of LOS which have looked at housing-related factors include a large Swiss analysis [12], which found that living conditions (including homelessness) was one of several variables strongly associated with LOS; an Australian study of LOS based on measures including the Health of the Nation Outcome Scales (HoNOS; [13]), which found a strong positive association with the HoNOS problems with living conditions item [14]; a large study of LOS in New York [15], which found a strong positive association with homelessness; a Californian study of a Veterans’ Administration Health Center with access for a “hoptel” for homeless patients enabling early discharge, which found, in contrast to the New York findings, and presumably due to the study intervention, that LOS for homeless patients did not differ from those who were housed [16]; and our own small case–control study of “long-stay” patients in psychiatric services serving four South London boroughs which found that long-stay was associated with need for rehousing [17]. "
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    ABSTRACT: Background A small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures. Methods Cross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression. Results Residential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor. Conclusions Homelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.
    Full-text · Article · Aug 2012 · BMC Psychiatry
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    • "outweigh benefits (Salit et al. 1998; Culhane, Metraux, and Hadley 2002; Rosenheck et al. 2003; Stefancic and Tsemberis 2007; Gilmer, Manning, and Ettner 2009; Larimer et al. 2009). We recently published the results of the first prospective, randomized controlled trial of adults who were homeless for 30 days or more and had any chronic medical illness. "
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    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.
    Full-text · Article · Nov 2011 · Health Services Research
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