Article

Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study

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Abstract

BACKGROUND Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations. OBJECTIVE The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness. DESIGNWe conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort. PARTICIPANTSThis study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005. MAIN MEASURESThe primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital. KEY RESULTSBetween 6 December 2004 and 31 March 2009, homeless participants (N = 203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR = 3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR = 2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR = 1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission. CONCLUSIONS Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population.

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... [8][9][10][11][12][13][14] As a result, homeless individuals have high levels of unmet healthcare needs 15,16 and higher rates of hospital admission and readmission compared to the general population. [17][18][19][20] Readmission to hospital has been a prominent area of focus for healthcare research to improve quality of care and reduce costs for health systems, but relatively few studies have examined readmissions in homeless populations. While the general Canadian and US populations have 30-day readmission rates of 9.4% and 13.9% respectively, 21, 22 the 30-day readmission rate among homeless populations ranges from approximately 20 to 50%. ...
... While the general Canadian and US populations have 30-day readmission rates of 9.4% and 13.9% respectively, 21, 22 the 30-day readmission rate among homeless populations ranges from approximately 20 to 50%. [18][19][20][23][24][25][26] Ninety-day readmission rates have been found to be within a similar range. 18,27,28 Identification of the factors associated with readmission among patients experiencing homelessness could provide insight for healthcare providers and policymakers to better support the transition from hospital to community for these individuals. ...
... 19, 23-25, 27, 28 In contrast, there is no clear evidence to suggest that age, sex or gender, alcohol or drug use, mental health-related conditions, and illness burden or number of chronic diseases are associated with higher readmission rates. 19,[23][24][25][27][28][29] Some studies have suggested that social support [30][31][32][33][34][35] and case management [36][37][38] improve health outcomes in this population, while having a primary care provider may benefit healthcare transitions; 19,24,25,27 accordingly, these factors need further exploration. ...
Article
Background: People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. Objective: To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. Design: This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. Participants: Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. Main measures: Unplanned all-cause readmission to the study hospital within 90 days of discharge. Key results: Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). Conclusion: Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.
... Due to repeat hospitalizations and hospitalizations for pregnancy-related causes, we expected there would be fewer total people with medical-surgical hospitalizations not related to pregnancy. Based on a study of another marginalized population in Ontario: people who were homeless [28], we expected that readmission rates would be as high as 22% for the prison group and 17% for the general population. Under those assumptions, we would have greater than 80% power to define readmission frequency for the prison group with a precision of 3% and 95% confidence with 733 people, and greater than 80% power to detect a difference in frequency of up to 5% with a two-sided alpha of 0.05 with 985 people in each exposure group. ...
... The findings of our study largely agree with previous evidence regarding increased morbidity in this population [8,32]. While studies on other marginalized populations with increased morbidity and barriers to care access such as people who are homeless and people with developmental disabilities have identified higher rates of readmission to hospital [28,33], we found no difference between rates of readmission for people in prison and we found decreased rates of readmission for people recently released from prison compared to the general population. ...
Article
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We aimed to compare 30-day readmission after medical-surgical hospitalization for people who experience imprisonment and matched people in the general population in Ontario, Canada. We used linked population-based correctional and health administrative data. Of people released from Ontario prisons in 2010, we identified those with at least one medical or surgical hospitalization between 2005 and 2015 while they were in prison or within 6 months after release. For those with multiple eligible hospitalizations, we randomly selected one hospitalization. We stratified people by whether they were in prison or recently released from prison at the time of hospital discharge. We matched each person with a person in the general population based on age, sex, hospitalization case mix group, and hospital discharge year. Our primary outcome was 30-day hospital readmission. We included 262 hospitalizations for people in prison and 1,268 hospitalizations for people recently released from prison. Readmission rates were 7.7% (95%CI 4.4–10.9) for people in prison and 6.9% (95%CI 5.5–8.3) for people recently released from prison. Compared with matched people in the general population, the unadjusted HR was 0.72 (95%CI 0.41–1.27) for people in prison and 0.78 (95%CI 0.60–1.02) for people recently released from prison. Adjusted for baseline morbidity and social status, hospitalization characteristics, and post-discharge health care use, the HR for 30-day readmission was 0.74 (95%CI 0.40–1.37) for people in prison and 0.48 (95%CI 0.36–0.63) for people recently released from prison. In conclusion, people recently released from prison had relatively low rates of readmission. Research is needed to elucidate reasons for lower readmission to ensure care quality and access.
... 6 To date, there is limited evidence documenting higher rates of hospital or emergency department (ED) revisit rates for homeless patients shortly after discharge from hospitals. However, existing research is limited to studies conducted in a single city, [7][8][9][10] and it remains unclear how generalizable these findings are to other regions in the USA. High rates of revisits among the homeless population following a hospitalization-which include hospital readmission or a return to the ED without requiring an admission-are quite costly to the U.S. health care system, and they may reflect suboptimal quality of care delivered to these patients or other unmet needs. ...
... Our findings were consistent with a small set of prior research suggesting higher rates of readmission and ED visits in the homeless population compared with the housed population. [7][8][9][10] However, these studies were limited to a single city, and therefore, it remains largely unclear whether their findings are generalizable to other regions. These studies also did not adjust for risk factors of hospital visits such as comorbidities and primary diagnoses, and thus, their estimates may have been biased due to confounding (e.g., the homeless may have experienced worse outcomes only because they have more comorbidities and were sicker). ...
Article
Full-text available
Background As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable.Objective To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients (“homeless-serving” hospitals—defined as hospitals in the top decile of the proportion of homeless patients).DesignA population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.ParticipantsParticipants were 3,527,383 patients (median age [IQR]: 63 [49–77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals.Main MeasuresRisk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.Key ResultsAfter adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69–2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74–2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.Conclusions Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.
... Prior studies suggest that homeless individuals may experience higher rates of readmission after an index hospitalization. [12][13][14] However, these studies have been limited by a relatively small sample size of patients J Gen Intern Med 35 (9):2576-83 experiencing homelessness or have only evaluated certain medical conditions or procedures. ...
... One study of 1165 homeless patients from a hospital in Toronto, Ontario, revealed a 30-day readmission rate of 22%, compared with a rate of 7% in a matched cohort of non-homeless patients. 12 A study of 331 homeless individuals in Harris County, TX, revealed a threefold higher rate of 30-day readmissions compared with housed individuals. 13 Another recent study of veterans discharged from the hospital after surgical procedures, which included 5068 homeless patients, found a 43% higher odds of readmission to the hospital associated with homelessness. ...
Article
Background Individuals experiencing homelessness have higher hospitalization and mortality rates compared with the housed. Whether they also experience higher readmission rates, and if readmissions vary by region or cause of hospitalization is unknown.Objective Evaluate the association of homelessness with readmission rates across multiple US states.DesignRetrospective analysis of administrative claimsPatientsAll inpatient hospitalizations in Florida, Massachusetts, and New York from January 2010 to October 2015Main MeasuresThirty- and 90-day readmission ratesKey ResultsOut of a total of 23,103,125 index hospitalizations, 515,737 were for patients who were identified as homeless at the time of discharge. After adjusting for cause of index hospitalization, state, demographics, and clinical comorbidities, 30-day and 90-day readmission rates were higher for index hospitalizations in the homeless compared with those in the housed group. The difference in 30-day readmission rates between homeless and housed groups was the largest in Florida (30.4% vs. 19.3%; p < 0.001), followed by Massachusetts (23.5% vs. 15.2%; p < 0.001) and New York (15.7% vs. 13.4%; p < 0.001) (combined 17.3% vs. 14.0%; p < 0.001). Among the most common causes of hospitalization, 30-day readmission rates were 4.1 percentage points higher for the homeless group for mental illness, 4.9 percentage points higher for diseases of the circulatory system, and 2.4 percentage points higher for diseases of the digestive system.Conclusions After adjusting for demographic and clinical characteristics, homelessness is associated with significantly higher 30- and 90-day readmission rates, with a significant variation across the three states. Interventions to reduce the burden of readmissions among individuals experiencing homelessness are urgently needed. Differences across states point to the potential of certain public policies to impact health outcomes for individuals experiencing homelessness.
... Thus, their health needs are especially complex and challenging to address (Frankish et al., 2005;Hwang, 2001). Because PWLEs have limited access to and use of primary healthcare, their main point of entry into the healthcare system is often hospitals and emergency departments (Hwang et al., 2011;Lin et al., 2015;Saab et al., 2016). In the 2020 Metro Vancouver homeless count, health services are among the most commonly accessed services for PWLEs: in the past year, 58% of respondents had used an emergency room, 49% had used the hospital for non-emergencies, and 44% had been in an ambulance (BCNPHA, 2020); each of these metrics increased from the 2017 homeless count (BCNPHA & M.Thomson Consulting, 2017). ...
... For instance, prior research has shown that permanent supportive housing models, including Housing First, can meet the health and psychosocial needs of PWLEs (Henwood et al., 2013;Padgett et al., 2015), though there remain challenges to this model of housing delivery when affordable housing is unavailable or inappropriate (Canham et al., 2019b). With worse health than general populations and reliance on high-cost hospitals and emergency departments (Frankish et al., 2005;Hwang, 2001;Hwang et al., 2011;Saab et al., 2016), discharge plans for PWLEs need to acknowledge the limited availability of affordable housing and offer short-term, transitional options for patients who require sub-acute rest and convalescence. Post-discharge programs that provide shelter/housing and case management while PWLEs are able to convalesce and/or access follow-up support should become the standard of care, particularly as there are significant cost savings to the healthcare system alongside improvements to individual outcomes (Biederman et al., 2019;Buchanan et al., 2006;Doran et al., 2013;Shetler & Shepard, 2018). ...
Article
Full-text available
Persons with lived and living experiences of homelessness (PWLEs) commonly use hospitals and emergency departments to access healthcare yet support for transitions from hospital to shelter/housing can be challenging to access. To improve the continuity of care and health outcomes for PWLEs who are being discharged from hospital, a more complete understanding of two hospital-to-shelter/housing programs in Metro Vancouver, Canada was sought. Using a community-based participatory research approach, we conducted in-depth interviews in-person or by phone. Participants included eight healthcare and shelter/housing decision-makers and providers and a convenience sample of ten program participants (two females and eight males who ranged in age from 31 to 74 years old; average = 50 years old). Data were analyzed in NVivo 12 to identify successes including: 1) achieving health stability and recovery following hospital discharge; 2) having privacy and freedom while in the program; 3) building relationships with providers; 4) having formal support to find housing; and 5) cross-sector relationships between providers. Challenges included: 1) limited availability of affordable and appropriate housing; 2) other guests’ ways of life; 3) complex needs versus limited after-care resources; and 4) inequities in program access. While hospital-to-shelter/housing programs can serve as intervention opportunities to connect PWLEs to permanent housing, discharge plans need to acknowledge the local limitations on housing availability and offer short-term options for patients who require sub-acute rest and convalescence.
... In addition, many health-care recommendations, such as dietary advice, can prove impossible without access to resources such as proper nutrition and cooking facilities (Hwang, 2001). This lack of appropriate access to community-based care and reliable social contexts to implement preventive health behaviors results in disproportionately high acute care use by people with lived experience of homelessness (Saab, Nisenbaum, Dhalla, & Hwang, 2016). This population frequently experiences longer hospital stays and a higher risk of unplanned readmission than the general population (Saab et al., 2016), as discharge planning is compromised by inadequate housing to return to and suboptimal structures to support proper follow-up care (Kushel, 2016). ...
... This lack of appropriate access to community-based care and reliable social contexts to implement preventive health behaviors results in disproportionately high acute care use by people with lived experience of homelessness (Saab, Nisenbaum, Dhalla, & Hwang, 2016). This population frequently experiences longer hospital stays and a higher risk of unplanned readmission than the general population (Saab et al., 2016), as discharge planning is compromised by inadequate housing to return to and suboptimal structures to support proper follow-up care (Kushel, 2016). ...
... The prevalent comorbidities and homelessness itself are combined with possibly inadequate control of chronic illness and lack of timely interventions for otherwise manageable acute illness, related to barriers in accessing medical care [4,5]. These factors likely underlie the high utilization of inpatient healthcare resources by the homeless, with high hospitalization and readmission rates and with higher inpatient costs, substantially exceeding those among their nonhomeless counterparts [6,7]. Acute health crises among the homeless can, in turn, progress to critical illness requiring care in the ICU. ...
Article
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Background The population-level demand for critical care services among the homeless (H) remains unknown, with only sparse data on the characteristics and outcomes of those managed in the ICU. Methods The Texas Inpatient Public Use Data File and annual federal reports were used to identify H hospitalizations and annual estimates of the H population between 2007 and 2014. The incidence of ICU admissions in the H population, the characteristics of ICU-managed H, and factors associated with their short-term mortality were examined. Results Among 52,206 H hospitalizations 15,553 (29.8%) were admitted to ICU. The incidence of ICU admission among state H population rose between 2007 and 2014 from 28.0 to 96.6/1,000 (p < 0.0001), respectively. Adults aged ≥ 45 years and minorities accounted for 70.2% and 57.6%, respectively, of the growth in volume of ICU admissions. Short-term mortality was 3.2%, with odds of death increased with age, comorbidity burden, and number of failing organs. Conclusions The demand for critical care services was increasingly high among the H and was contrasted by low short-term mortality among ICU admissions. These findings, coupled with the persistent health disparities among minority H, underscore the need to effectively address homelessness and reduce barriers to longitudinal appropriate prehospital care among the H.
... 13,14 This finding may be influenced by inability to follow medication planning, as well as socioeconomic status, employment, education, and social support, among other social determinants of health. 15,16 Additionally, homeless patients are at higher risks of being readmitted to the hospital than those who are discharged to home, motels, nursing facilities or rehabilitation. 17 Homelessness predisposes patients to lessened control over social distance and living conditions and a greater risk of exposure without proper access to protective materials. ...
Article
Background: Hospital readmissions are associated with poor patient outcomes and increased health resource utilization. The need to study readmission patterns is even bigger during a pandemic because the burden is further stretching the healthcare system. Methods: We reviewed the initial hospitalization and subsequent readmission for 19 patients with confirmed COVID-19 in the largest statewide hospital network in Rhode Island, US, from March 1st through April 19th , 2020. We also compared the characteristics and clinical outcomes between readmitted and non-readmitted patients. Results: Of the 339 hospitalized patients with COVID-19, 279 discharged alive. Among them, 19/279 were readmitted (6.8%) after a median of 5 days. There was a significantly higher rate of hypertension, diabetes, chronic pulmonary disease, liver disease, cancer, and substance abuse among the readmitted compared to non-readmitted patients. The most common reasons of readmissions happening within 12 days from discharge included respiratory distress and thrombotic episodes, while those happening at a later time included psychiatric illness exacerbations and falls. The length of stay during readmission was longer than during index admission and more demanding on healthcare resources. Conclusion: Among hospitalized patients with COVID-19, those readmitted had a higher burden of comorbidities than the non-readmitted. Within the first 12 days from discharge, readmission reasons were more likely to be associated with COVID-19, while those happening later were related to other reasons. Readmissions characterization may help in defining optimal timing for patient discharge and ensuring safe care transition.
... 6 Housing-unstable patients also experience frequent hospital readmission and place a burden on emergency department services. [7][8][9][10] Because of housing's interrelationship with health, unstable housing contributes to unhealthier patients and burdens health systems. ...
Article
US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.
... People experiencing homelessness face numerous obstacles to accessing appropriate healthcare and frequently present at hospital with advanced disease conditions and potentially lifethreatening illness [1]. Given their lack of a secure, stable place to live, deficiencies in the quality of care and disproportionate exposure to substance and frequent alcohol consumption, homeless people may exhibit increased rates of prior acute health service use, including emergency department, hospital admissions [2,3] unplanned readmissions [4], prolonged hospital lengths of stay (LOS) and more costly care than those who are domiciled [5][6][7][8]. ...
Article
Background No research was conducted on the clinical characteristics and outcomes of Infectious Disease Units (IDU) managed homeless patients (HP). Methods We conducted retrospectively a survey among 98 HP and 98 non-HP admitted between 2017 and 2018 in several IDUs in Marseille, France. Results HP were more likely to be migrant, to report frequent alcohol consumption or illicit drug use, and to present with respiratory symptoms at admission compared to controls. The most common final diagnoses in HP were respiratory tract infections (other than pulmonary tuberculosis [PTB], 35.7%), sexually transmitted infections (20.4%), cutaneous and mucosal infections (19.4%) and tuberculosis (12.2%). Sexually transmitted infections and ectoparasite infestations were significantly more frequent in HP compared to controls. One HP died from pleural effusion as a complication of PTB. The surviving HP had a longer length of stay (LOS, average 11.6 ± 13.6 days, p < 0.0001) than controls; independent factors of increased LOS were tobacco use (p = 0.009), tuberculosis infection (p < 0.0001), urinary tract infection (p = 0.018) and bacteraemia (p = 0.018). After hospital discharge, attendance at subsequent planned consultations was significantly lower in HP (0.72 ± 1.25 times/persons) compared to controls (2.03 ± 2.2). Conclusions We suggest that HP present specific demographic characteristics and patterns of infectious diseases compared to other patients and require adapted management.
... Lack of housing has been recognized as an independent risk factor for rehospitalization after an index admission for various medical conditions. 19,20 We found a 100% increase in 30-day readmission in homeless patients after an index admission for AMI. The etiology of this is likely multifactorial and include the higher rates of discharge against medical advice, financial barriers to elective follow-up, the inability to afford, or the lack of adherence to essential medications. ...
Article
Objective To study the in-hospital outcomes and 30-day readmission data in homeless patients admitted with acute myocardial infarction (AMI). Methods Adult patients (>18 years of age) who were admitted with AMI between January 1, 2015, and December 31, 2016, were identified in the National Readmission Database. Patients were classified into homeless or non-homeless. Baseline characteristics, rates of invasive assessment and revascularization, mortality, 30-day readmission rates, and reasons for readmission were compared between the 2 cohorts. Results A total of 3938 of 1,100,241 (0.4%) index hospitalizations for AMI involved homeless patients. Compared with non-homeless patients, homeless patients were younger (mean age, 57±10 years vs 68±14 years; P<.001) and had a lower prevalence of atherosclerotic risk factors (hypertension, hyperlipidemia, and diabetes) but a higher prevalence of anxiety, depression, and substance abuse. Homeless patients were less likely to undergo coronary angiography (38.1% vs 54%; P<.001), percutaneous coronary intervention (24.1% vs 38.7%; P<.001), or coronary artery bypass grafting (4.9% vs 6.7%; P<.001). Among patients who underwent percutaneous coronary intervention, bare-metal stent use was higher in homeless patients (34.6% vs 12.1%; P<.001). After propensity score matching, homeless patients had similar mortality but higher rates of acute kidney injury, discharge to an intermediate care facility or against medical advice, and longer hospitalizations. Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%; P<.001). Homeless patients had more readmissions for psychiatric causes (18.0% vs 2.0%; P<.001). Conclusion Considerable differences in cardiovascular risk profile, in-hospital care, and rehospitalization rates were observed in the homeless compared with non-homeless cohort with AMI. Measures to remove the health care barriers and disparities are needed.
... 8,9 Pharmacist reinforcement of medication adherence can help deter chronic disease exacerbations and provide cost-savings to health care institutions. 8,[10][11][12] Nonadherence in the general population is common, ranging from 25% to 50%. 13 Homeless patients have shown even higher rates of medication nonadherence for any given chronic illness, [14][15][16] and the complexity of chronic disease management among the homeless population warrants the use of innovative health care interventions to avoid deteriorating medical conditions. ...
Article
Objective: The aim of this study was to analyze the effect of clinical pharmacy services on health outcomes and medication adherence concerning hypertension and diabetes in the homeless population. Methods: This was a retrospective quasi-experimental study conducted between January 1, 2015, and December 31, 2016. The primary outcomes included median blood pressure and median glycosylated hemoglobin (A1C) change from baseline. The secondary end points included adherence to hypertension and diabetes medication, in addition to the differences in the number of admissions to urgent care clinics, emergency departments, or hospitals pre- and postpharmacist clinic visit. Results: One-hundred ninety-eight homeless patients were seen by a pharmacist over the study time frame, and 116 of these patients were included. There was a decrease in systolic and diastolic blood pressure in the 6-months postpharmacist visit (139 mm Hg vs. 135 mm Hg, P = 0.413, and 85 mm Hg vs. 82 mm Hg, P = 0.197, respectively). The percentage of patients who met the blood pressure goals increased from 55% to 66% (P = 0.093). A statistically significant decrease in A1C was found (7.7% vs 7.2%, P = 0.038). The number of patients who met the A1C goal increased from 20% to 41% (P = 0.267) after pharmacist intervention. No medication class was associated with a median proportion of days covered (PDC) of 80% or greater. However, differences were seen with biguanides (34% vs. 43%, P = 0.004), calcium channel blockers (44% vs. 59%, P < 0.001), and thiazides (28% vs. 39%, P = 0.039) pre- and postintervention. There was no difference in the number of visits to emergency departments or urgent care clinics, or hospitalizations. Conclusion: Homeless patients with hypertension and/or type 2 diabetes who had at least 1 visit with a pharmacist showed some improved health outcomes. Statistically significant benefits were seen in diabetes management, but not for blood pressure control.
... Dozens of studies across subspecialties show that discharge AMA is consistently associated with hospital readmission in general medical patients across a large variety of medical conditions and various time frames after discharge. 3,6,[9][10][11][12][13][14][15][16][17][18][19] These readmissions are responsible for the 56% greater-than-expected costs associated with treatment for patients who leave the hospital AMA. 20 Patients with discharge AMA are also less likely to seek needed follow-up care due to concerns about being negatively judged by physicians. ...
Article
Approximately 1-2% of hospitalizations in the United States result in an against medical advice (AMA) discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.
... As a result of limited access to, and use of, primary healthcare, the main point of entry into the healthcare system for adults experiencing homelessness is often hospitals and emergency departments (EDs) Saab, Nisenbaum, Dhalla, & Hwang, 2016). Khandor and Mason (2007) reported that hospital EDs were the most frequently used source of healthcare for persons experiencing homelessness in Toronto, with 5% reporting hospital EDs as their only usual source of healthcare. ...
... This situation further exacerbates the health challenges of homeless families and as such there is a need for better policies and programs to address these challenges. Furthermore, the frequent use of emergency services does not promote effective continuity of care (Lamanna et al., 2018) and is costly (Saab et al., 2016) as compared to the use of primary health services. ...
Article
Full-text available
Purpose The purpose of this paper is to report the findings of a scoping review on the health challenges of families experiencing homelessness. There is a bi-directional relationship between health and homelessness in that poor health can increase the risk of housing loss, and experiencing homelessness is bad for one’s health. The experience of homelessness differs between populations and this review focuses on families as one of the fastest growing segments of the homeless population. While research has been integrated on the causes of homelessness for families, this same integration has not been conducted looking at health challenges of families experiencing homelessness. Design/methodology/approach A scoping review methodology is utilized in the paper. As the goal of this work is to ultimately develop interventions for a Canadian context, primacy is given to Canadian sources, but other relevant literature is also included. Findings A clear distinction is seen in the literature between health challenges of children of homeless families and health challenges of parents. These themes are explored separately, and preliminary recommendations are made for potential points of intervention as personal, program and policy levels. Originality/value This review of current evidence is an important first step in building a foundation for interventions to improve health outcomes for those experiencing housing loss.
... Despite these high needs, access to ambulatory health services is known to be low in this population. Homeless individuals with mental health problems are more likely to use acute care settings (hospitalisations (Chambers et al., 2013;Saab et al., 2016) and emergency departments (ED) (Kushel et al., 2002;Arfken et al., 2004)) and less likely to receive general primary care (Khandor et al., 2011) and outpatient mental health services (Folsom et al., 2005). However, little is known about the quality of care for homeless individuals discharged following a psychiatric hospitalisation to the street or to shelters (Burra et al., 2012), despite the fact that the month following discharge from a psychiatric ward is a period of high risk and high need . ...
Article
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Aims A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care. Methods This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 ( N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge. Results There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26–1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68–2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40–0.53)). Conclusion Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.
... First, limited research has been done on whether social isolation plays a role in overall health care use (8,9). Second, the measure of social isolation is typically collected outside the EHR, via selfreported survey or interview (5,(10)(11)(12). Thus, these measures are rarely found in analyses of administrative inpatient data. ...
Article
INTRODUCTION: The effect of social factors on health care outcomes is widely recognized. Health care systems are encouraged to add social and behavioral measures to electronic health records (EHRs), but limited research demonstrates how to leverage this information. We assessed 2 social factors collected from EHRs - social isolation and homelessness - in predicting 30-day potentially preventable readmissions (PPRs) to hospital. METHODS: EHR data were collected from May 2015 through April 2017 from inpatients at 2 urban hospitals on O'ahu, Hawai'i (N = 21,274). We performed multivariable logistic regression models predicting 30-day PPR by living alone versus living with others and by documented homelessness versus no documented homelessness, controlling for relevant factors, including age group, race/ethnicity, sex, and comorbid conditions. RESULTS: Among the 21,274 index hospitalizations, 16.5% (3,504) were people living alone and 11.2% (2,385) were homeless; 4.2% (899) hospitalizations had a 30-day PPR. In bivariate analysis, living alone did not significantly affect likelihood of a 30-day PPR (16.6% [3,376 hospitalizations] without PPR vs 14.4% [128 hospitalizations] with PPR; P = .09). However, documented homelessness did show a significant effect on the likelihood of 30-day PPR in the bivariate analysis (11.1% [2,259 hospitalizations] without PPR vs 14.1% [126 hospitalizations] with PPR; P = .006). In multivariable models, neither living alone nor homelessness was significantly associated with PPR. Factors that were significantly associated with PPR were comorbid conditions, discharge disposition, and use of an assistive device. CONCLUSION: Homelessness predicted PPR in descriptive analyses. Neither living alone nor homelessness predicted PPR once other factors were controlled. Instead, indicators of physical frailty (ie, use of an assistive device) and medical complexity (eg, hospitalizations that required assistive care post-discharge, people with a high number of comorbid conditions) were significant. Future research should focus on refining, collecting, and applying social factor data obtained through acute care EHRs.
... This phenomenon disproportionately affects vulnerable populations and has been associated with worse health outcomes. For example, in a matched-cohort study of 203 homeless individuals and 203 low-income controls, Saab et al. [24] found that homeless patients who were discharged against medical advice were twice as likely to be readmitted to the hospital compared to those who were not. Furthermore, these kinds of discharges have been shown to stigmatize patients, reduce the quality of care and undermine access to health services [22,25,26]. ...
Article
Background Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS. Methods We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare. Results A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388–52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79–2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7–1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08–4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4–0.8; p = 0.01). Conclusion Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.
... As a result of limited access to, and use of, primary healthcare, the main point of entry into the healthcare system for homeless adults is often hospitals and EDs (Hwang et al., 2011;Saab, Nisenbaum, Dhalla, & Hwang, 2016). Khandor and Mason (2007) reported that hospital EDs were the most frequently used source of healthcare for persons experiencing homelessness in Toronto, with 5% reporting hospital EDs as their only usual source of healthcare. ...
Article
Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow‐up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after‐care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma‐informed care and patient‐ or client‐centred care approaches are discussed.
... Furthermore, people experiencing homelessness struggle to meet the basic needs such as food, shelter, and transportation, resulting in self-management of chronic health conditions being overlooked or neglected [12][13][14]. These barriers and competing priorities contribute to adverse outcomes, including reliance on emergency departments (EDs) or hospitals for nonemergent health care services and increased risk of 30-day hospital readmissions [15][16][17]. ...
Preprint
BACKGROUND In the U.S., the number of people experiencing homelessness (PEH) has continually increased for the last 3 years.Homelessness is associated with poor health, and PEH are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite a high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations. OBJECTIVE To investigate how access to smartphone technology facilitates self-management including attainment of social needs within the context of homelessness. METHODS A secondary analysis of 33 exit interviews from two feasibility studies related to mHealth interventions among people experiencing homelessness (PEH) was conducted. Iterative thematic analysis was used to identify themes representative of participants’ experiences using smartphone technology. RESULTS Collectively, participants revealed how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having the smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management. CONCLUSIONS PEH used the tools on a smartphone to make decisions, take action, solve problems, and utilize resources – skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to Smartphone technology and transportation empowered participants to meet requirements for attainment of social needs.
... [9][10][11] As a result, outcomes after hospital discharge may be poor, and studies in the USA have shown that homeless inpatients are more likely to be readmitted than housed inpatients. [12][13][14][15] In response to concerns about poor discharge arrangements for homeless inpatients, the UK government set up the 'Homeless Hospital Discharge Fund', 16 which funded partnerships of National Health Service (NHS) and non-profit organisations to develop methods of supported discharge. These schemes operated between 2013 and 2016 and used a range of models. ...
Article
Full-text available
Background Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission. Methods We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios. Results After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients. Conclusions Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.
... [9][10][11][12] Together, these factors contribute to high rates of hospital service use and costs. [13][14][15] Given increasing rates of homelessness and the impact of homelessness on health, 16 there is an urgent need for interventions to improve health outcomes in this population, including avoidable hospital service utilization. 14 For adults experiencing mental illness, care following discharge from hospital for a mental health condition is reportedly the most important factor in reducing reliance on subsequent inpatient care. ...
Article
Objective This study evaluated the impact of a critical time intervention (CTI) adaptation on health care utilization outcomes among adults experiencing homelessness and mental health needs in a large urban center. Methods Provincial population-based administrative data from Ontario, Canada, were used in a pre–post design for a cohort of 197 individuals who received the intervention between January 2013 and May 2014 and were matched to a cohort of adults experiencing homelessness who did not receive the intervention over the same time period. Changes in health care utilization outcomes in the year pre- and postintervention were evaluated using generalized estimating equations, and post hoc analyses evaluated differences between groups. Results Pre–post analyses revealed statistically significant changes in health care utilization patterns among intervention recipients, including reduced inpatient service use and increased outpatient service use in the year following the intervention compared to the year prior. However, the matched cohort analysis found nonsignificant differences in health service use changes between a subgroup of intervention recipients and their matched counterparts. Conclusions An adapted CTI model was associated with changes in health care utilization among people experiencing homelessness and mental health needs. However, changes were not different from those observed in a matched cohort. Rigorous study designs with adequate samples are needed to examine the effectiveness of CTI and local adaptations in diverse health care contexts.
... The structural stigma they experience when accessing health or social services is a major cause of their health inequities (Hatzenbuehler et al., 2013). For example, people with lived experience of homelessness with coexisting mental health conditions report specific barriers to accessing care, such as being unaware of the location of care, affordability, wait times and having experienced previous (Saab et al., 2016), as discharge planning is compromised by inadequate housing to return to and suboptimal structures to support proper follow up care (Kushel, 2016). ...
Article
Full-text available
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, −$19, −$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
... People with social risk factors such as homelessness are often discharged from hospital into inadequate living conditions, including rough sleeping. 26 Attending outpatient appointments and adhering to antibiotic regimens can be challenging in these conditions. Second, the RRS at Olallo House provides DOT for all residents and achieves high rates of treatment fidelity which may not be the case for patients treated under DOT in the community. ...
Article
Full-text available
Background Many countries are seeking to eliminate tuberculosis (TB), but incidence remains high in socially excluded groups such as people experiencing homelessness. There is limited research into the effectiveness of residential respite services (RRS), which provide accomodation and social and clinical support for homeless people with active TB. Methods We used a register of all cases of TB diagnosed in London between 1 January 2010 and 3 October 2019 to compare characteristics and outcomes of patients treated in an RRS with patients receiving standard care. The primary outcome was successful treatment completion. We used logistic regression to compare likelihood of completing treatment, and simulation to estimate the absolute change in treatment completion resulting from this service. Results A total of 78 homeless patients finished an episode of TB treatment at the RRS. Patients treated in the RRS were more likely than patients treated in standard care to have clinical and social risk factors including drug resistance, history of homelessness, drug or alcohol use, and need for directly observed therapy. After adjusting for these factors, patients treated in the RRS had 2.97 times the odds of completing treatment (95% CI = 1.44–6.96). Treatment ended in failure for 8/78 patients treated in the RRS (10%, 95% CI = 5%–20%). We estimated that in the absence of the RRS, treatment would have ended in failure for 17/78 patients (95% CI = 11–25). Conclusion The residential respite service for homeless TB patients with complex social needs was associated with better treatment outcomes.
... 34 Housing insecurity is also associated with higher rates of hospitalization and readmission. 35,36 Patients with social risk factors may face barriers to followup including low health literacy and an inability to obtain transportation to appointments. Increasing the use of telehealth services for health education and convenient virtual follow-up appointments could increase rates of timely follow-up. ...
Article
Background: Previous studies have identified disparities in readmissions among Medicare beneficiaries hospitalized for the Hospital Readmissions Reduction Program's (HRRP's) priority conditions. Evidence suggests timely follow-up is associated with reduced risk of readmission, but it is unknown whether timely follow-up reduces disparities in readmission. Objective: To assess whether follow-up within 7 days after discharge from a hospitalization reduces risk of readmission and mitigates identified readmission disparities. Design: A retrospective cohort study using Cox proportional hazards models to estimate the associations between sociodemographic characteristics (race and ethnicity, dual-eligibility status, rurality, and area social deprivation), follow-up, and readmission. Mediation analysis was used to examine if disparities in readmission were mitigated by follow-up. Participants: We analyzed data from 749,402 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, or pneumonia, and discharged home between January 1 and December 1, 2018. Main measure: All-cause unplanned readmission within 30 days after discharge. Key results: Post-discharge follow-up within 7 days of discharge was associated with a substantially lower risk of readmission (HR: 0.52, 95% CI: 0.52-0.53). Across all four HRRP conditions, beneficiaries with dual eligibility and beneficiaries living in areas with high social deprivation had a higher risk of readmission. Non-Hispanic Black beneficiaries had higher risk of readmission after hospitalization for pneumonia relative to non-Hispanic Whites. Mediation analysis suggested that 7-day follow-up mediated 21.2% of the disparity in the risk of readmission between dually and non-dually eligible beneficiaries and 50.7% of the disparity in the risk of readmission between beneficiaries living in areas with the highest and lowest social deprivation. Analysis suggested that after hospitalization for pneumonia, 7-day follow-up mediated nearly all (97.5%) of the increased risk of readmission between non-Hispanic Black and non-Hispanic White beneficiaries. Conclusions: Improving rates of follow-up could be a strategy to reduce readmissions for all beneficiaries and reduce disparities in readmission based on sociodemographic characteristics.
... Combined with accompanying challenges in accessing preventive and primary healthcare Fazel, Geddes, & Kushel, 2014), people experiencing homelessness use the acute health care system at higher rates than the general population (Hwang et al., 2013;Hwang, Weaver, Aubry, & Hoch, 2011). Studies from the UK (Lewer et al., 2021), USA (Doran, Ragins, Iacomacci, et al., 2013;Kertesz et al., 2009;Khatana et al., 2020) and Canada (Saab, Nisenbaum, Dhalla, & Hwang, 2016;Wang et al., 2021) report higher rates of unplanned hospital readmission among unhoused patients than the general population, which suggests that their post-discharge recovery needs are not being met in the community (Canham, Davidson, et al., 2019). Hospital discharge is an important point of care transition that can be leveraged to improve the health of unhoused patients and reduce hospital readmissions. ...
Article
Full-text available
Hospital discharge is a key transition in a patient's care pathway, providing an effective point of intervention to address a patient's ongoing health and social care needs. Addressing these needs may prevent hospital readmissions. The hospital discharge process for people experiencing homelessness who have been admitted for medical conditions has not been well-characterized. To address this gap in knowledge, we interviewed hospital and shelter workers, and key informants, about their experiences when unhoused patients are discharged from hospitals to shelters. Using critical realism, we explored the organizational and service context of this process by looking at the relationship between structures and agency in the daily work of our participants. Our results indicate that the discharge process for unhoused patients was shaped by two systems failures, barriers to publicly funded systems including community resources, and silos and gaps between these systems, ultimately leading to failed transitions to the community. The most prominent manifestations of these systems failures were a) limited and inadequate access to post-discharge care and services, b) barriers to accessing shelters, c) inadequate service integration between healthcare and social service sectors, and, d) poor cross-sectoral knowledge between hospital and shelter workers. We characterize the discharge process for unhoused patients as a part of a larger systems failure in the care for unhoused patients and contend that improvements in hospital discharges requires changes to underlying structures that lead to inadequate discharges.
... Housing has become a vested interest for hospitals since 2013, when the Hospital Readmissions Reduction Program (HRRP) reduced Medicare payments to hospitals with comparatively high rates of readmission (CMS 2019). Readmission rates among unhoused patients are three times those of housed patients, so hospitals are increasingly interested in the net gains that housing their patients might produce (Saab et al. 2016). ...
Article
As medicine integrates social and structural determinants into health care, some health workers redefine housing as medical treatment. This article discusses how health workers in two U.S. urban safety‐net hospitals worked with patients without stable housing. We observed ethnographically how health workers helped patients seek housing in a sharply stratified housing economy. Analyzing in‐depth interviews and observations, we show how health workers: (1) understood housing as health care and navigated limits of individual care in a structurally produced housing crisis; and (2) developed and enacted practices of biomedical and sociopolitical stabilization, including eligibilizing and data‐tracking work. We discuss how health workers bridged individually focused techniques of clinical care with structural critiques of stratified housing economies despite contradictions in this approach. Finally, we analyze the implications of providers’ extension of medical stabilization into social, economic, and political realms, even as they remained caught in the structural dynamics they sought to address.
... The discharge process for people experiencing homelessness is not well characterized in the Canadian context. Research primarily examines hospital length of stay and discharge outcomes such as hospital readmission (Hwang et al., 2011;Hwang et al., 2013;Saab et al., 2016), or discharge from long-term and acute mental healthcare (Forchuk et al., 2013). Less research focuses on discharge after hospitalization for physical health conditions, despite frequent admissions and long lengths of stay for homeless patients admitted to medical and surgical services (Hwang et al., 2011). ...
Article
Objectives A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. Methods Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. Results Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. Conclusion Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.
... Furthermore, people experiencing homelessness struggle to meet the basic needs such as food, shelter, and transportation, resulting in self-management of chronic health conditions being overlooked or neglected [12][13][14]. These barriers and competing priorities contribute to adverse outcomes, including reliance on emergency departments (EDs) or hospitals for nonemergent health care services and increased risk of 30-day hospital readmissions [15][16][17]. ...
Article
Background In the United States, the number of people experiencing homelessness has continually increased over the last 3 years. Homelessness is associated with poor health, and people experiencing homelessness are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite the high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations. Objective This study aims to investigate how access to smartphone technology facilitates self-management, including the attainment of social needs within the context of homelessness. Methods A secondary analysis of 33 exit interviews from 2 feasibility studies related to mobile health interventions among people experiencing homelessness was conducted. Iterative thematic analysis was used to identify themes representative of participants’ experiences using smartphone technology. Results Collectively, participants revealed not only how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having a smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management. Conclusions People experiencing homelessness used the tools on a smartphone to make decisions, take action, solve problems, and use the resources—skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to smartphone technology and transportation empowered participants to meet the requirements for the attainment of social needs.
... These distinctions are important, given both our results here and that patients discharged AMA are also more likely to report experiencing homelessness, prior TBI, and readmissions for hospital care (14,15,27,28). Relatedly, patients reporting higher levels of psychiatric and substance use comorbidities are more likely to be discharged AMA, and homeless patients specifically have a higher likelihood of being discharged AMA (15,28), and to be readmitted for hospital care (12,(29)(30)(31). Additionally, the retrospective definition for homelessness here lacks specificity regarding homelessness type ((un)sheltered, individual, family, military veteran, or chronic), as well as the reasons for and durations of homelessness episodes, which can directly impact risk for neurotrauma, and decisions regarding continuums of care during hospital stay and post-discharge. ...
Article
Full-text available
Primary Objective Established literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations. Research Design We leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home. Methods and Procedures We implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups. Main Outcomes and Results Homelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home. Conclusion Given the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.
... 8,24 Discharge disposition is a complex task for the homeless population that involves a balance between finding a proper placement and managing long hospital stays for patients at risk of leaving AMA. 25 Existing treatment strategies for homeless burn patients should be assessed and tailored to meet the needs of this population. This may include minimizing hospital stays and increasing accessibility to discharge resources like recuperative care centers and street medicine teams, which are designed to bridge the outpatient wound care needs of homeless patients. ...
Article
Tent fires are a growing issue in regions with large homeless populations given the rise in homelessness within the US and existing data that suggest worse outcomes in this population. The aim of this study is to describe the characteristics and outcomes of tent fire burn injuries in the homeless population. A retrospective review was conducted involving two verified regional burn centers with patients admitted for tent fire burns between January 2015 and December 2020. Variables recorded include demographics, injury characteristics, hospital course, and patient outcomes. Sixty-nine patients met the study inclusion criteria. The most common mechanisms of injury were by portable stove accident, assault, and tobacco or methamphetamine-related. Median percent total body surface area (%TBSA) burned was 6% (IQR 9%). Maximum depth of injury was partial thickness in 65% (n=45) and full thickness in 35% (n=24) of patients. Burns to the upper and lower extremities were present in 87% and 54% of patients, respectively. Median hospital Length-of-Stay (LOS) was 10 days (IQR=10.5) and median ICU LOS was 1 day (IQR=5). Inhalation injury was present in 14% (n=10) of patients. Surgical intervention was required in 43% (n=30) of patients, which included excision, debridement, skin grafting, and escharotomy. In-hospital mortality occurred in 4% (n=3) of patients. Tent fire burns are severe enough to require inpatient and ICU level of care. A high proportion of injuries involved the extremities and pose significant barriers to functional recovery in this vulnerable population. Strategies to prevent these injuries are paramount.
... However, having patients who are experiencing homelessness at admission is problematic for hospitals that are striving for excellence in their quality indicators such as readmission rates. In one hospital a matched sample comparing individuals experiencing homelessness to non-homeless, the patients reporting experience of homelessness had nearly 4 times the odds of being readmitted compared to the non-homeless (Saab et al., 2016). Veterans experiencing homelessness have been reported to be more likely to be readmitted to the hospital in a study of veteran patients (Titan et al., 2018). ...
Article
Background: Individuals experiencing homelessness have a high prevalence of infectious diseases that may result in hospitalization. Objectives: This study uses risk factors at baseline to predict hospitalization at follow-up. This paper also presents the associations between reporting homelessness and selected infectious diseases. Research design: Longitudinal study of baseline and follow-up conducted August 2000 through July 2014. Subjects: 4916 Not experiencing homelessness mean age 37.9 years, 29% female, and 2692 experiencing homelessness age 42.1 years, 29% female received services from a research/service center in a low-income, high-crime area of Long Beach, CA. Measures: Risk Behavior Assessment, Risk Behavior Follow-up Assessment, laboratory testing for hepatitis A, hepatitis B, hepatitis C, syphilis, chlamydia, and gonorrhea. Results: Predictors of hospitalization at follow-up were ever use of crack cocaine, income from Social Security or disability, reporting homelessness, female, and those who identify as Black race/ethnicity. Conclusions: Income from the safety net of Social Security or disability provides participants with experience that transfers to being able to obtain healthcare. A higher proportion of those experiencing homelessness, compared to those not experiencing homelessness, appear to be hospitalized at follow-up. Our findings support use of the Frailty Framework when working with individuals experiencing both homelessness and hospitalization.
Article
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.
Article
Introduction: Homeless Veterans are vulnerable to poor care transitions, yet little research has examined their risk of readmission following inpatient surgery. This study investigates the predictors of surgical readmission among homeless relative to housed Veteran patients. Methods: Inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration from 2008 to 2014 were identified. Administrative International Classification of Diseases, Ninth Revision, Clinical Modification codes and Veterans Health Administration clinic stops were used to identify homeless patients. Bivariate analyses examined characteristics and predictors of readmission among homeless patients. Multivariate logistic models were used to estimate the association between homeless experience and housed patients with readmission following surgery. Results: Our study included 232,373 surgeries: 43% orthopedic, 39% general, and 18% vascular with 5068 performed on homeless patients. Homeless individuals were younger (56 vs. 64 y, P<0.01), more likely to have a psychiatric comorbidities (51.3% vs. 19.4%, P<0.01) and less likely to have other medical comorbidities such as hypertension (57.1% vs. 70.8%, P<0.01). Homeless individuals were more likely to be readmitted [odds ratio (OR), 1.43; confidence interval (CI), 1.30-1.56; P<0.001]. Discharge destination other than community (OR, 0.57; CI, 0.44-0.74; P<0.001), recent alcohol abuse (OR, 1.45; CI, 1.15-1.84; P<0.01), and elevated American Society Anesthesiologists classification (OR, 1.86; CI, 1.30-2.68; P<0.01) were significant risk factors associated with readmissions within the homeless cohort. Conclusions: Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.
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Introduction Homelessness is associated with increased acute care utilization and poor healthcare outcomes. This study aims to compare hospital readmission rates among patients experiencing homelessness and patients who are not homeless and assess the impact of different clinical and demographic characteristics on acute care utilization among patients experiencing homelessness. Methods This was a retrospective study of patients encountered in 2018 and 2019 at ChristianaCare Health Systems. The analysis was done in August 2021. The prevalence of major chronic conditions among patients experiencing homelessness (n=1,329) and those not experiencing it (n=143,360) was evaluated. Patients experiencing homelessness were matched with nonhomeless patients using 1:1 propensity score matching. Time-to-event analysis approaches were used to analyze time-to-readmission and 30-day readmission rates. Results The 30-day readmission rates were 42.2% among patients experiencing homelessness and 19.9% among matched patients not experiencing homelessness. The hazard of 30-day readmission among patients experiencing homelessness was 2.6 (95% CI=1.93, 3.53) times higher than that among the matched nonhomeless cohort. In patients experiencing homelessness, drug use disorder, major depressive disorder, chronic kidney disease, obesity, arthritis, HIV/AIDS, and epilepsy were associated with shortened time to readmission. Moreover, Black racial identity was associated with shortened time to readmission. Conclusions Patients experiencing homelessness had higher acute care utilization than those not experiencing homelessness. Black racial identity and several comorbidities were associated with increased acute care utilization among patients experiencing homelessness. Efforts to address upstream social determinants of health, destigmatization, and healthcare management accounting for the whole spectrum of clinical comorbidities might be important in promoting the health of people experiencing homelessness.
Article
Background Frostbite is a high morbidity, high-cost injury that can lead to digit or limb necrosis requiring amputation. Our primary aim is to describe the rate of readmission following frostbite injury. Our secondary aims are to describe the overall burden of care, cost, and characteristics of repeat hospitalizations of frostbite-injured people. Methods Hospitalizations following frostbite injury (index and readmissions) were identified in the 2016 and 2017 Nationwide Readmission Database. Multivariable logistic regression was clustered by hospital and additionally adjusted for severe frostbite injury, gender, year, payor group, severity, and comorbidity index. Population estimates were calculated and adjusted for by using survey weight, sampling clusters, and stratum. Results In the two-year cohort, 1,065 index hospitalizations resulted in 1,907 total hospitalizations following frostbite injury. Most patients were male (80.3%), lived in metropolitan/urban areas (82.3%), and nearly half were insured with Medicaid (46.4%). Of the 842 readmissions, 53.7% were associated with complications typically associated with frostbite injury. Overall, 29% of frostbite injuries resulted in at least one amputation. The average total cost and total LOS of readmissions was $236,872 and 34.7 days. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission. Factors associated with multiple readmissions include discharge AMA and Medicare Insurance, but not drug or alcohol abuse or homelessness. The population-based estimated unplanned readmission rate following frostbite injury was 35.4% (95% CI 32.2 – 38.6%). Conclusions This is the first study examining readmissions following frostbite injury on a national level. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission, while only AMA discharge and Medicare insurance were associated with multiple readmissions. Supportive resources (community and hospital-based) may reduce unplanned readmissions of frostbite injured patients with those additional risk factors.
Article
Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.
Article
Background: Readmission followed by surgery to treat spinal fractures has a substantial impact on patient care costs and reflects a hospital's quality standards. This article analyzes the factors associated with hospital readmission followed by surgery to treat spinal fractures. Methods: This was a cross-sectional study with time-series analysis. For prediction analysis, we used Cox proportional hazards and machine-learning models, using data from the Healthcare Cost and Utilization Project, Inpatient Database from Florida (USA). Results: The sample comprised 215,999 patients, 8.8% of whom were readmitted within 30 days. The factors associated with a risk of readmission were male sex (1.1 [95% confidence interval 1.06-1.13]) and >60 years of age (1.74 [95% CI: 1.69-1.8]). Surgeons with a higher annual patient volume presented a lower risk of readmission (0.61 [95% CI: 0.59-0.63]) and hospitals with an annual volume >393 presented a lower risk (0.92 [95% CI: 0.89-0.95]). Conclusion: Surgical procedures and other selected predictors and machine-learning models can be used to reduce 30-day readmissions after spinal surgery. Identification of patients at higher risk for readmission and complications is the first step to reducing unplanned readmissions.
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Introduction: High rates of early hospital discharge are often observed in crack cocaine users, being related to adverse outcomes, and increased public spending. This study evaluated clinic and sociodemographic factors associated with early treatment discharge among crack users. Methods: The sample included 308 men diagnosed with crack cocaine use disorder (crack only), between 18 to 65 years of age, admitted between 2013 and 2017 in a male hospital unit to treat substance use disorders. Sociodemographic and clinical data were obtained using the Addiction Severity Index, 6th version, and a Sociodemographic Questionnaire. Results: Early discharge (within 7 days) was significantly associated with lack of own income, insufficient family support, being single, and recent homelessness. Regarding drug use, lower treatment retention was related to younger age of crack use onset, recent alcohol use and nicotine use. Factors such as age, skin color, and education level showed no relation to the outcome. Conclusion: Our findings suggest that the presence of characteristics verifiable at the time of admission may be related to crack users' treatment retention. The identification of these factors can contribute to target interventions in order to improve treatment adherence in crack cocaine users.
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ABSTRACT Background and Aim: Readmission rate is very important due to its impact on cost, quality of healthcare, and putting additional burden on the hospitals and patients. The aim of this study was to evaluate the rate of patient's readmission after discharge from educational and medical hospitals in Sanandaj in 2018. Materials and Methods: This descriptive cross-sectional study included all the patients admitted to the educational and medical hospitals in Sanandaj twice or more times in 2018. SPSS software version 23 was used for data analysis. Descriptive statistics were used for drawing frequency distribution tables for qualitative variables. Mean values with 95% the confidence interval was calculated for quantitative variables. Results: The results of the study revealed 7623 readmissions in educational and medical hospitals of Sanandaj in 2018 which included 4373 (57.3%) female and 3250 (42.7%) male patients. In general, the most common cause of readmission belonged to follow-up (38.9%). Other causes of readmission were recurrence of the condition (26%) and treatment complications (21.8%). Conclusion: Considering the high readmission rates in Sanandaj hospitals, the development of community-based health services, especially homecare centers and local clinics, is recommended. Keywords: Hospital readmission, Hospitals, Hospitalization
Article
Hospital to Housing (H2H) is a Department of Veteran Affairs (VA) program providing medical respite care to veteran's experiencing homelessness. The program partners community organizations providing transitional housing with local VA facilities delivering medical care for post-hospitalization veterans for clinical stabilization and ultimately, permanent housing. The program was launched October 2017 at 43 sites. Using mixed methods, we aim to assess participant health services utilization and community partner perceptions and experiences with the implementation of the program. We collected 90-day pre/post-enrollment health care utilization data for the first 200 H2H enrollees and conducted semi-structured interviews with six community organizations. Veterans enrolled in H2H had a significant decline in utilization of emergency department and inpatient care (67.0% vs. 39.5%, p < 0.01) and a significant increase in primary care utilization (47.5% vs. 78.0%, p < 0.01). The greatest barrier to implementation was concern of patient complexity while the greatest enabler was the perceived value/benefit of the program. Our findings suggest a community-partnered low intensity medical respite model for select lower acuity populations is feasible to operate and can substantially redirect care away from acute care settings and increase primary care and social services engagement.
Article
Background: National efforts are underway to reduce hospital readmissions. Few studies have used administrative data to provide a global view of readmission among people experiencing homelessness, who often utilize multiple hospital systems. Objective: To examine the 30-day hospital readmission rate and factors associated with readmission following discharge among homeless Medicaid members in Massachusetts. Methods: We analyzed medical record and Medicaid administrative data for 1269 hospitalizations between 2013 and 2014 for 458 unique patients attributed to Boston Health Care for the Homeless Program. Generalized Estimating Equations were used to investigate factors associated with readmission. Results: Of all hospitalizations, 27% resulted in readmission, more than double the average national Medicaid readmission rate. Leaving against medical advice was associated with increased readmission, while having a Health Care for the Homeless primary care practitioner was associated with reduced readmission. Among the most frequently admitted individuals, being discharged to medical respite care was associated with reduced readmission. Conclusions: To break the readmission cycle, health care providers serving homeless individuals could focus on assuring access to medical respite care and extending outreach efforts that increase primary care engagement. This may be especially important for accountable care systems, as safety net providers increasingly assume financial risk for patients' total cost and quality of care.
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This section explores the challenges of discharging patients who are homeless and reviews solutions other cities have implemented to combat these issues. Homeless people experience poor access to healthcare, which can lead to delays in diagnosis and necessary care. It has a significant impact on hospitals and the course of treatment for these patients as they have a higher need for acute services and often longer and more expensive hospital stays. Without increased attention to these issues, including education for medical programs and financial support and resources, it will be challenging to provide the needed support to this population.
Chapter
This chapter focuses on one highly specific aspect of homelessness, the need for increased programs in medical respite for the homeless. That is because many persons who have experienced homelessness just prior to an acute care hospital admission are simply not well enough to return to shelters or the streets when their acute care needs have been met. Some of these patients move into sub-acute or long-term care settings. But for many, a different kind of environment is needed. What are needed are programs designed explicitly for the previously homeless patient, programs that provide the full range of medical, psychiatric, physical and occupational, spiritual, and social services designed to meet the particular needs of these patients. The country presently lacks the kind of excellent medical respite programs that this large acute care hospital population needs and deserves. Increasing the handful of such programs would advance the well-being of these patients and take a significant care burden off the physicians, nurses, and social workers who care for these patients while in the hospital and at discharge. Also, being able to move patients into excellent medical respite programs could be highly financially advantageous for the hospitals. This chapter presents a picture of how the problem developed and some thinking about the evolution of solutions. Then the chapter moves from where we are to where we should be, concluding with a brief presentation of some examples and thoughts for next steps.
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Patients anticipating surgery and anesthesia often need preoperative care to lower risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges are vital to reducing disparities in health and health care.
Article
Providing quality healthcare for homeless patients is a major public health challenge, and some hospitals may be better at treating homeless patients than others. However, whether the quality of care that homeless patients receive differs by the teaching status of hospitals remains unclear. Using statewide databases that include all hospital admissions and emergency department (ED) visits in four states (Florida, Massachusetts, Maryland, and New York) in 2014, we compared 30-day readmission and ED revisit rates for homeless and non-homeless patients discharged from teaching hospitals versus non-teaching hospitals, after adjusting for patient and hospital characteristics. Among 3,438,538 patients (median age [IQR]: 63 [49-77] years) analyzed, 132,025 (4%) were homeless patients. Overall, homeless patients had a higher readmission rate (28.3% vs. 17.7%; average marginal effects [AME], 10.5%; 95% confidence interval [CI], 8.2% to 12.9%; p<0.001) and a higher ED revisit rate (37.6% vs. 23.9%; AME, 13.7%; 95%CI, 10.9% to 16.6%; p<0.001) than non-homeless patients. Patients from teaching hospitals had similar readmission rate (18.2% vs. 18.3%; AME, -0.1%; 95%CI, -0.8% to 0.5%; p=0.69) and slightly lower ED revisit rate than those from non-teaching hospitals (24.1% vs. 25.2%; AME, -1.1%; 95%CI, -1.9% to -0.3%; p<0.01). When we focus on joint effects of homelessness and hospital teaching status, we found that homeless patients treated at teaching hospitals had lower rates of 30-day readmission (AME, -5.8%; 95%CI, -9.7% to -1.8%; p<0.01) and ED revisit (AME, -9.3%; 95%CI, -13.1% to -5.5%; p<0.001) compared to those treated at non-teaching hospitals. For non-homeless patients, in contrast, we found no evidence that rates of hospital readmission (AME, 0%, 95%CI, -0.1% to 0.1%; p=0.94) or ED revisit (AME, -0.9%; 95%CI, -1.7% to -0.1%; p=0.02) differ between teaching and non-teaching hospitals. These findings suggest the healthcare settings in which homeless patients receive care have important implications for their patient outcomes.
Article
Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.
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Background: Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. Methods: In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. Results: Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18-2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99-2.21; between-person OR 3.04, CI 2.79-3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. Interpretation: Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.
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Homeless individuals have mortality rates three to six times higher than their housed counterparts and have elevated rates of mental illness, substance abuse, and co-morbidities that increase their need for health services. Data on the utilization of Harris County, Texas' public hospital system by 331 homeless individuals and a random sample of 17,824 domiciled patients were obtained from June 2008 to July 2009. Homeless individuals had increased readmission rates, especially within 30 days of discharge, resulting in significantly higher total annual length of stay. Homeless patients also more frequently utilize public hospitals for mental illness and HIV. Lack of community health services contributes to an increased dependence and preventable over-utilization of public hospital systems. Case management interventions integrating primary and behavioral care into health homes, medical respite programs, and training for health care professionals who provide indigent care will improve health outcomes of this population and reduce costs.
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We compared the readmission rates and the pattern of readmission among patients discharged against medical advice (AMA) to control patients discharged with approval over a one-year follow-up period. A retrospective matched-cohort study of 656 patients(328 were discharged AMA) who were followed for one year after their initial hospitalization at an urban university-affiliated teaching hospital in Vancouver, Canada that serves a population with high prevalence of addiction and psychiatric disorders. Multivariate conditional logistic regression was used to examine the independent association of discharge AMA on 14-day related diagnosis hospital readmission. We fit a multivariate conditional negative binomial regression model to examine the readmission frequency ratio between the AMA and non-AMA group. AMA patients were more likely to be homeless (32.3% vs. 11%) and have co-morbid conditions such as psychiatric illnesses, injection drug use, HIV, hepatitis C and previous gastrointestinal bleeding. Patients discharged AMA were more likely to be readmitted: 25.6% vs. 3.4%, p<0.001 by day 14. The AMA group were more likely to be readmitted within 14 days with a related diagnosis than the non-AMA group (Adjusted Odds Ratio 12.0; 95% Confidence Interval [CI]: 3.7-38.9). Patients who left AMA were more likely to be readmitted multiple times at one year compared to the non-AMA group (adjusted frequency ratio 1.6; 95% CI: 1.3-2.0). There was also higher all-cause in-hospital mortality during the 12-month follow-up in the AMA group compared to non-AMA group (6.7% vs. 2.4%, p = 0.01). Patients discharged AMA were more likely to be homeless and have multiple co-morbid conditions. At one year follow-up, the AMA group had higher readmission rates, were predisposed to multiple readmissions and had a higher in-hospital mortality. Interventions to reduce discharges AMA in high-risk groups need to be developed and tested.
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Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models. To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk. Prospective observational cohort study. Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts. We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk. Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, >or=1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of >or=25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively. Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission.
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Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This article examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital.
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Standardized instruments are widely used to assess homeless persons, but basic data on their reliability and validity in these populations have not been available. The purpose of this study was to examine the reliability of standardized instruments used in a cooperative agreement on homeless persons with substance use disorder. This study examined the 1-week test-retest reliability of the Alcohol Dependence Scale, the Addiction Severity Index and the Personal History Form, using 189 randomly selected subjects participating in a multisite study of services for homeless persons with alcohol and other drug abuse problems. In addition to scales and items, factors hypothesized to influence reliability related so subject, interviewer and setting were examined. Results showed substantial reliability for scale scores (> .60) but mixed reliability for individual items. Reliability was greater when items were factual and based on a recent time interval, and when subjects were interviewed in a protected setting. Higher reliability was also related to younger age, female gender, a first episode of homelessness and lower severity of psychiatric problems. Reliability should be examined in individual studies of homeless persons, and efforts should be made to minimize controllable sources of unreliability.
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Retrospective self-reports of behavior are widely used in alcohol and drug research. However, assessments of the reliability and validity of such data among certain populations are nonexistent. This study examines the ability of the Addiction Severity Index (ASI), a widely used clinical and research instrument, to provide valid and reliable data within a homeless population of drug misusers. The results support the usefulness of the ASI in producing quality data among homeless substance misusers seeking treatment. Qualitative data gathered from field interviewers are used to highlight strategies for enhancing the quality of ASI data in the future.
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Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.
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The Pathways Into Homelessness project in Toronto interviewed 300 unaccompanied adult users of homeless shelters to identify characteristics of individuals who are homeless for the first time. The sample reflected the total population of homeless shelter users in terms of age, sex, level of use, and type of shelter. Two fifths of the sample were homeless for the first time. There were more similarities than differences between those who were homeless for the first time and those who had been homeless previously. The prevalence of psychiatric and substance use disorders and the rate of previous hospitalization did not differ between first-time homeless persons and those who had been homeless before. The two groups were distinguished by some childhood experiences related to housing. Both groups had multiple indicators of serious problems, suggesting that the need for intervention is as pressing for persons who are homeless for the first time as it is for the larger population of homeless persons.
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Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes and readmission. In this study we examined rates of readmission and predictors of readmission among patients leaving hospital AMA. We prospectively studied 97 consecutive patients who left the general medicine service of an urban teaching hospital AMA. Each patient was matched according to age, sex and primary diagnosis with a control patient who was discharged routinely. Readmission rates were examined using Kaplan-Meier analysis. Regression models were used to test the hypothesis that readmissions among patients discharged AMA followed a biphasic curve. Patients who left AMA were much more likely than the control patients to be readmitted within 15 days (21% v. 3%, p < 0.001). Readmissions occurred at an accelerated pace during the first 15 days, followed by a 75-day period during which readmissions occurred at a rate comparable to that among the control patients. Among the patients who left AMA, being male and having a history of alcohol abuse were significant predictors of readmission within 15 days; however, these characteristics were common among the patients who left AMA. In the Cox proportional hazard models, leaving AMA was the only significant predictor of readmission (adjusted hazard ratio 2.5, 95% confidence interval 1.4-4.4). The significantly increased risk of readmission among general medicine patients who leave hospital AMA is concentrated in the first 2 weeks after discharge. However, it is difficult to identify which patients will likely be readmitted.
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The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about 730 million US dollars. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.
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Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
Article
Objectives: We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. Methods: We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). Results: Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. Conclusions: In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
Article
Objectives: We identified factors associated with inpatient hospitalizations among a population-based cohort of homeless adults in Toronto, Ontario. Methods: We recruited participants from shelters and meal programs. We then linked them to administrative databases to capture hospital admissions during the study (2005-2009). We used logistic regression to identify predictors of medical or surgical and psychiatric hospitalizations. Results: Among 1165 homeless adults, 20% had a medical or surgical hospitalization, and 12% had a psychiatric hospitalization during the study. These individuals had a total of 921 hospitalizations, of which 548 were medical or surgical and 373 were psychiatric. Independent predictors of medical or surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization. Conclusions: Health care need was a strong predictor of medical or surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults were potentially avoidable, whereas others represented an unavoidable use of health services.
Article
National attention is increasingly focused on hospital readmissions. Little prior research has examined readmissions among patients who are homeless. The aim of the study was to determine 30-day hospital readmission rates among patients who are homeless and examine factors associated with hospital readmissions in this population. We conducted a retrospective chart review of patients who were homeless and hospitalized at a single urban hospital from May-August 2012. Homelessness was identified by an electronic medical record flag and confirmed by manual chart review. The primary outcome was all-cause hospital readmission to the study hospital within 30 days of hospital discharge. Patient-level and hospitalization-level factors associated with risk for readmission were examined using generalized estimating equations. There were 113 unique patients who were homeless and admitted to the hospital a total of 266 times during the study period. The mean age was 49 years, 27.4% of patients were women, and 75.2% had Medicaid. Half (50.8%) of all hospitalizations resulted in a 30-day hospital inpatient readmission and 70.3% resulted in either an inpatient readmission, observation status stay, or emergency department visit within 30 days of hospital discharge. Most readmissions occurred early after hospital discharge (53.9% within 1 week, 74.8% within 2 weeks). Discharge to the streets or shelter versus other living situations was associated with increased risk for readmission in multivariable analyses. Patients who were homeless had strikingly high 30-day hospital readmission rates. These findings suggest the urgent need for further research and interventions to improve postdischarge care for patients who are homeless.
Article
Objective. To evaluate the construct validity of the Short Form 12-item Survey (SF-12) among users of a homeless day shelter. Adding brief health assessments has potential to provide information regarding the effect that programs have upon the health status and functioning of homeless persons.Study Setting. A convenience sample of 145 homeless persons at a day shelter in an urban setting.Study Design. Participants were verbally administered the SF-12 that provides information on mental and physical health status and the Dartmouth Improve Your Medical Care SurveyTM (IYMC) that provides information on functional health, clinical symptoms, medical conditions, and health risk. The IYMC survey system has been widely used in clinical settings to assess health status and the outcomes of care.Data Collection/Extraction Methods. Construct validity was assessed by the following approaches: (a) the method of extreme groups was used where multivariate analysis of variance determined if SF-12 summary scores varied for individuals who differed in self-reported clinical symptoms and medical conditions, and (b) convergent validity was assessed by correlating SF-12 summary scores with the subscales.Principal Findings. Four to 10 point differences in physical health (PCS12) and 5–11 point differences in mental health (MCS12) were found between those who reported acute symptoms and medical conditions and those who did not. A 13-point difference in PCS12 scores and a 7–16-point difference in MCS12 scores were found for those who reported none or few to several symptoms or conditions. The summary scores and subscales yielded satisfactory convergent validity coefficients that ranged from 0.62 to 0.88 with one exception.Conclusions. The SF-12 shows promise as a valid outcome indicator for assessing and monitoring health status among the homeless. Its strengths include brevity and availability of norms for specific medical conditions.
Article
Medical respite programs provide care to homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization. They are designed to improve the health of homeless patients while also decreasing costly hospital use. Although there is increasing interest in implementing respite programs, there has been no prior systematic review of their effectiveness. We conducted a comprehensive search for studies of medical respite program outcomes in multiple biomedical and sociological databases, and the grey literature. Thirteen articles met inclusion criteria. The articles were heterogeneous in methods, study quality, inclusion of a comparison group, and outcomes examined. Available evidence showed that medical respite programs reduced future hospital admissions, inpatient days, and hospital readmissions. They also resulted in improved housing outcomes. Results for emergency department use and costs were mixed but promising. Future research utilizing adequate comparison groups is needed.
Article
To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients. A cross-sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five-year period (July 1, 1993, to June 30, 1998). A "frequent user" visited the ED five or more times in a 12-month period. Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi-Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year. Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.
Article
The hospital readmission rate has been proposed as an important outcome indicator computable from routine statistics. However, most commonly used measures raise conceptual issues. We sought to evaluate the usefulness of the computerized algorithm for identifying avoidable readmissions on the basis of minimum bias, criterion validity, and measurement precision. A total of 131,809 hospitalizations of patients discharged alive from 49 hospitals were used to compare the predictive performance of risk adjustment methods. A subset of a random sample of 570 medical records of discharge/readmission pairs in 12 hospitals were reviewed to estimate the predictive value of the screening of potentially avoidable readmissions. Potentially avoidable readmissions, defined as readmissions related to a condition of the previous hospitalization and not expected as part of a program of care and occurring within 30 days after the previous discharge, were identified by a computerized algorithm. Unavoidable readmissions were considered as censored events. A total of 5.2% of hospitalizations were followed by a potentially avoidable readmission, 17% of them in a different hospital. The predictive value of the screen was 78%; 27% of screened readmissions were judged clearly avoidable. The correlation between the hospital rate of clearly avoidable readmission and all readmissions rate, potentially avoidable readmissions rate or the ratio of observed to expected readmissions were respectively 0.42, 0.56 and 0.66. Adjustment models using clinical information performed better. Adjusted rates of potentially avoidable readmissions are scientifically sound enough to warrant their inclusion in hospital quality surveillance.
Article
Homeless adults visit emergency departments (EDs) nearly 4 times more often than the general population and are among the highest repeat visitors. Little research, however, has determined resource utilization patterns of homeless patients and the extent to which they may benefit from emergency care. The objectives of this study are to describe emergency medical services and hospital utilization by homeless patients and to estimate their benefit of ED care. This was a retrospective cohort study performed at an urban safety-net hospital. All patients who presented to the ED during 2003 were identified. Simple random samples of 300 homeless adult patients and 300 nonhomeless adult patients were identified and included as the study sample. Variables collected included patient demographics, medical history, ED visit date and times, results of laboratory studies, disposition from the ED, diagnoses, ambulance use, number of previous ED visits, and estimated benefit of emergency treatment as determined by a previously developed consensus-based instrument. Homeless patients were slightly older (41 years [interquartile range (IQR) 34 to 48 years] versus 36 years [IQR 25 to 46 years]) and had substantially higher substance abuse histories but had similar medical and psychiatric comorbidities compared with nonhomeless patients. Homeless patients also spent more time in the ED per visit (4.4 hours [IQR 2.6 to 7.5 hours] versus 3.8 hours (IQR 2.1 to 5.7 hours]), were less likely to be admitted to the hospital (8% versus 19%), and were more likely to use ambulance services (51% versus 29%). Finally, homeless patients received a similar level of estimated benefit of emergency treatment compared with nonhomeless patients, and a substantial proportion of their visits was directly related to excessive alcohol use. Homeless adults commonly use emergency care resources, and medical benefit, although comparable to that of nonhomeless adults, is in many cases uncertain.
Chapter 2: Homeless People
  • Sw Hwang
  • Jr Dunn
Homelessness: programs and the people they serve. Findings of the National Survey of Homeless Assistance Providers and Clients
  • Mr Burt
  • Ly Aron
  • E Lee