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: 35.29). 06/2009; 301(17):1771-8. DOI: 10.1001/jama.2009.561
Source: PubMed


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.

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    • "This study is the first large-scale attempt to assess the applicability of the Housing First model on homeless people with serious mental illness in France. Several studies have provided evidence regarding the effectiveness of the Housing First model in North American contexts [15,16,21,23,54,61]. However, the extent to which the Housing First model could be replicated in France needs to be rigorously investigated [30]. "
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    ABSTRACT: Recent studies in North American contexts have suggested that the Housing First model is a promising strategy for providing effective services to homeless people with mental illness. In the context of the highly generous French national health and social care system, which is easily accessible and does not require out-of-pocket payment, the French Health Ministry insists on rigorous techniques, including randomized protocols, to evaluate the impact of Housing First approaches in France.Method and design: A prospective randomized trial was designed to assess the impact of a Housing First intervention on health outcomes and costs over a period of 24 months on homeless people with severe mental illness, compared to Treatment-As-Usual. The study is being conducted in four cities in France: Lille, Marseille, Paris and Toulouse. The inclusion criteria are as follows: over 18 years of age, absolutely homeless or in precarious housing, and possessing a 'high' level of need: diagnosis of schizophrenia or bipolar disorder and moderate to severe disability according to the Multnomah Community Ability Scale (score <= 62) and at least one of the following three criteria: 1) having been hospitalized for mental illness two or more times in any one year during the preceding five years; 2) co-morbid alcohol or substance use; and 3) having been recently arrested or incarcerated. Participants will be randomized to receiving the Housing First intervention or Treatment-As-Usual. The Housing First intervention provides immediate access to independent housing and community care. The primary outcome criterion is the use of high-cost health services (that is,, number of hospital admissions and number of emergency department visits) during the 24-month follow-up period. Secondary outcome measures include health outcomes, social functioning, housing stability and contact with police services. An evaluation of the cost-effectiveness and cost-utility of Housing First will also be conducted. A total of 300 individuals per group will be included. This is the first study to examine the impact of a Housing First intervention compared to Treatment-As-Usual in France. It should provide key information to policymakers concerning the cost-effectiveness and health outcomes of the Housing First model in the French context.Trial registration: The current clinical trial number is NCT01570712.
    Full-text · Article · Sep 2013 · Trials
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    • "Providing resources to emergency physicians when caring for homeless patients may improve outcomes for patients and reduce emergency physicians’ burden of care. For instance, intensive case management has been shown to reduce emergency department use and result in better health outcomes by connecting homeless clients with available community resources [25-27]. "
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    ABSTRACT: Medical students' attitudes and beliefs about homeless people may be shaped by the attitudes of their teachers and one of the most common sites for learning about homeless patients is the emergency department. The objective of this study was to determine if medical students in the preclinical and clinical years and emergency medicine faculty and residents have different attitudes and beliefs about homeless people. The Health Professional Attitudes Toward the Homeless Inventory (HPATHI), was administered to all medical students, and emergency medicine physicians and residents at a large academic health sciences center in Canada. The HPATHI examines attitudes, interest and confidence on a 5-point Likert scale. Differences among groups were examined using the Kruskal Wallis test and Pearson's chi-square test. The HPATHI was completed by 371 individuals, for an overall response rate of 55%. Analysis of dichotomized median and percentage results revealed 5/18 statements were significant by both methods. On the attitudes subscales physicians and residents as a group were more negative for 2/9 statements and on the confidence subscale more positive for 1/4 statements. The interest subscale achieved overall statistical significance with decreased positive responses among physicians and residents compared to medical students in 2/5 statements. This study revealed divergences in attitudes, interests and beliefs among medical students and emergency medicine physicians and residents. We offer strategies for training interventions and systemic support of emergency faculty. Emergency medicine physicians can examine their role in the development of medical students through both formal and informal teaching in the emergency department.
    Full-text · Article · Aug 2013 · BMC Medical Education
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    • "In addition to reduced substance use and abuse [14], some of the key outcomes differentiating HFM from abstinence-based programs are: fewer emergency room visits and hospitalizations [15]; higher perceived choice in services [16,17]; reduced involvement in criminal activity [18]; and higher housing retention rates [19,20]. The United States Interagency Council on Homelessness and the National Alliance to End Homelessness became advocates of the HFM after programs based on its demonstrated ability to retain consumers in housing (i.e., residential stability) [4,6]. "
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    ABSTRACT: Background The Housing First Model (HFM) is an approach to serving formerly homeless individuals with dually diagnosed mental health and substance use disorders regardless of their choice to use substances or engage in other risky behaviors. The model has been widely diffused across the United States since 2000 as a result of positive findings related to consumer outcomes. However, a lack of clear fidelity guidelines has resulted in inconsistent implementation. The research team and their community partner collaborated to develop a HFM Fidelity Index. We describe the instrument development process and present results from its initial testing. Methods The HFM Fidelity Index was developed in two stages: (1) a qualitative case study of four HFM organizations and (2) interviews with 14 HFM "users". Reliability and validity of the index were then tested through phone interviews with staff members of permanent housing programs. The final sample consisted of 51 programs (39 Housing First and 12 abstinence-based) across 35 states. Results The results provided evidence for the overall reliability and validity of the index. Conclusions The results demonstrate the index’s ability to discriminate between housing programs that employ different service approaches. Regarding practice, the index offers a guide for organizations seeking to implement the HFM.
    Full-text · Article · May 2013 · Substance Abuse Treatment Prevention and Policy
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