Health Care Utilization Patterns of Homeless Individuals in Boston: Preparing for Medicaid Expansion Under the Affordable Care Act
Monica Bharel is with the Boston Health Care for the Homeless Program and the Department of Medicine, Massachusetts General Hospital and Boston Medical Center, Boston. Wen-Chieh Lin, Jianying Zhang, Elizabeth O'Connell, and Robin E. Clark are with the Center for Health Policy and Research, University of Massachusetts Medical School, Boston. Wen-Chieh Lin and Robin E. Clark are with the Department of Family Medicine and Community Health, University of Massachusetts Medical School. At the time of the study, Robert Taube was with the Boston Health Care for the Homeless Program. American Journal of Public Health
(Impact Factor: 4.55).
10/2013; 103(S2). DOI: 10.2105/AJPH.2013.301421
We studied 6494 Boston Health Care for the Homeless Program (BHCHP) patients to understand the disease burden and health care utilization patterns for a group of insured homeless individuals.
We studied merged BHCHP data and MassHealth eligibility, claims, and encounter data from 2010. MassHealth claims and encounter data provided a comprehensive history of health care utilization and expenditures, as well as associated diagnoses, in both general medical and behavioral health services sectors and across a broad range of health care settings.
The burden of disease was high, with the majority of patients experiencing mental illness, substance use disorders, and a number of medical diseases. Hospitalization and emergency room use were frequent and total expenditures were 3.8 times the rate of an average Medicaid recipient.
The Affordable Care Act provides a framework for reforming the health care system to improve the coordination of care and outcomes for vulnerable populations. However, improved health care coverage alone may not be enough. Health care must be integrated with other resources to address the complex challenges presented by inadequate housing, hunger, and unsafe environments.
Available from: Stacey Scriver
- "2 - 24% of the homeless population have been found to have this diagnosis ( Bharel et al . , 2013 ; Wright et al . , 2003 ) ."
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ABSTRACT: Homelessness is a primary concern for community health. Scientific literature on homelessness is wide ranging and diverse. One opportunity to add to existing literature is the development and testing of affordable, easily implemented methods for measuring the impact of homeless on the healthcare system. Such methodological approaches rely on the strengths in a multidisciplinary approach, including providers, both healthcare and homeless services and applied clinical researchers. This paper is a proof of concept for a methodology which is easily adaptable nationwide, given the mandated implementation of homeless management information systems in the United States and other countries; medical billing systems by hospitals; and research methods of researchers. Adaptation is independent of geographic region, budget restraints, specific agency skill sets, and many other factors that impact the application of a consistent methodological science based approach to assess and address homelessness. We conducted a secondary data analysis merging data from homeless utilization and hospital case based data. These data detailed care utilization among homeless persons in a small, Appalachian city in the United States. In our sample of 269 persons who received at least one hospital based service and one homeless service between July 1, 2012 and June 30, 2013, the total billed costs were $5,979,463 with 10 people costing more than one-third ($1,957,469) of the total. Those persons were primarily men, living in an emergency shelter, with pre-existing disabling conditions. We theorize that targeted services, including Housing First, would be an effective intervention. This is proposed in a future study.
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ABSTRACT: Study objective:
We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.
We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.
Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.
Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.
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