Article

Hospital Costs and Length of Stay Among Homeless Patients Admitted to Medical, Surgical, and Psychiatric Services

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Abstract

Homeless individuals often suffer from serious health conditions and are frequently hospitalized. This study compares hospitalization costs for homeless and housed patients, with and without adjustment for patient and service characteristics. Administrative data on 93,426 admissions at an academic teaching hospital in Toronto, Canada, were collected over a 5-year period. These data included an identifier for patients who were homeless. Each admission was allocated a cost in Canadian dollars based on Ontario Case Costing methodology. Associations between homeless status and cost were examined for the entire sample and stratified by medical, surgical, and psychiatric services. Data were analyzed for 90,345 housed patient admissions (mean cost, 12,555)and3081homelesspatientadmissions(meancost,12,555) and 3081 homeless patient admissions (mean cost, 13,516). After adjustment for age, gender, and resource intensity weight, homeless patient admissions cost 2559morethanhousedpatientadmissions(952559 more than housed patient admissions (95% CI, 2053, 3066).Forpatientsonmedicalandsurgicalservices,muchofthisdifferencewasexplainedbymorealternatelevelofcaredaysspentinthehospital,duringwhichpatientsdidnotrequirethelevelofservicesprovidedinanacutecarefacility.Homelesspatientadmissionsonthepsychiatricservicecost3066). For patients on medical and surgical services, much of this difference was explained by more alternate level of care days spent in the hospital, during which patients did not require the level of services provided in an acute care facility. Homeless patient admissions on the psychiatric service cost 1058 more than housed patient admissions (95% CI, 480, 1635) even after adjustment for length of stay. Homeless patients on medical and surgical services remain hospitalized longer than housed patients, resulting in substantial excess costs. Homeless patients admitted for psychiatric conditions have higher costs not explained by prolonged length of stay. These observations may help guide development of community-based interventions for homeless individuals and reduce their use of inpatient care.

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... In general, IEH spend between 2.3 and 4.1 more days in hospital [8][9][10] than housed individuals. Hwang et al. noted that in Canada, even after adjustment for age, gender, and resource intensity weight, hospitalisations for IEH cost over $2500 more than for housed individuals [11]. Concomitant mental health concerns are common in IEH and impact both rates of hospital admissions, LOS, and hospitalisation costs [12], with admissions to psychiatry costing over $1000 more for IEH after adjusting for length of stay [11]. ...
... Hwang et al. noted that in Canada, even after adjustment for age, gender, and resource intensity weight, hospitalisations for IEH cost over $2500 more than for housed individuals [11]. Concomitant mental health concerns are common in IEH and impact both rates of hospital admissions, LOS, and hospitalisation costs [12], with admissions to psychiatry costing over $1000 more for IEH after adjusting for length of stay [11]. ...
... Maternal concerns associated with homelessness also demonstrated increased LOS with 6.45 more days spent in the hospital, again demonstrating specific needs for community prenatal and foetal-maternal care for IEH. Given longer stays in hospital for IEH, the lack of housing security has a direct economic impact on acute care; our findings also support previous work showing increased hospital costs for IEH [11]. The major driver to costs is length of stay given similar rates of hospitalisation. ...
Article
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Background Individuals experiencing homelessness (IEH) tend to have increased length of stay (LOS) in acute care settings, which negatively impacts health care costs and resource utilisation. It is unclear however, what specific factors account for this increased LOS. This study attempts to define which diagnoses most impact LOS for IEH and if there are differences based on their demographics. Methods A retrospective cohort study was conducted looking at ICD‐10 diagnosis codes and LOS for patients identified as IEH seen in Emergency Departments (ED) and also for those admitted to hospital. Data were stratified based on diagnosis, gender, and age. Statistical analysis was conducted to determine which ICD‐10 diagnoses were significantly associated with increased ED and inpatient LOS for IEH compared to housed individuals. Results Homelessness was associated with increased LOS regardless of gender or age group. The absolute mean difference of LOS between IEH and housed individuals was 1.62 h [95% CI 1.49–1.75] in the ED and 3.02 days [95% CI 2.42–3.62] for inpatients. Males age 18–24 years spent on average 7.12 more days in hospital, and females aged 25–34 spent 7.32 more days in hospital compared to their housed counterparts. Thirty‐one diagnoses were associated with increased LOS in EDs for IEH compared to their housed counterparts; maternity concerns and coronary artery disease were associated with significantly increased inpatient LOS. Conclusion Homelessness significantly increases the LOS of individuals within both ED and inpatient settings. We have identified several diagnoses that are associated with increased LOS in IE; these should inform the prioritisation and development of targeted interventions to improve the health of IEH.
... Homelessness and housing instability are significant public health challenges in Canada, with one in five Canadians directly or indirectly affected [1] People experiencing homelessness have consistent disparities in adverse health outcomes and mortality compared to housed counterparts [2][3][4], even after accounting for potential confounders such as socioeconomic status and comorbidities [4,5]. These disparities have historically resulted in this population incurring notably high average healthcare costs relative to housed individuals [6][7][8][9][10][11][12][13][14]. ...
... Our results extend previous work from before the COVID-19 pandemic in Canada [6][7][8][9], the US [10,11,40], the UK [12], Denmark [13], and Australia [14]. In all of these settings, people experiencing homelessness are shown to have substantial healthcare costs. ...
... In all of these settings, people experiencing homelessness are shown to have substantial healthcare costs. In a few of these studies, costs are also shown to be much higher than for housed patients not experiencing homelessness [6,10]. The vast majority of this literature [6,10,[12][13][14] assessed costs among patients experiencing homelessness, who by definition require some amount of eligible healthcare to be included. ...
Article
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Background Evidence is limited about healthcare cost disparities associated with homelessness, particularly in recent years after major policy and resource changes affecting people experiencing homelessness occurred after the onset of the COVID-19 pandemic. We estimated 1-year healthcare expenditures, overall and by type of service, among a representative sample of people experiencing homelessness in Toronto, Canada, in 2021 and 2022, and compared these to costs among matched housed and low-income housed individuals. Methods Data from individuals experiencing homelessness participating in the Ku-gaa-gii pimitizi-win cohort study were linked with Ontario health administrative databases. Participants (n = 640) were matched 1:5 by age, sex-assigned-at-birth and index month to presumed housed individuals (n = 3,200) and to low-income presumed housed individuals (n = 3,200). Groups were followed over 1 year to ascertain healthcare expenditures, overall and by healthcare type. Generalized linear models were used to assess unadjusted and adjusted mean cost ratios between groups. Results Average 1-year costs were 12,209(9512,209 (95% CI 9,762-14,656)amongparticipantsexperiencinghomelessnesscomparedto14,656) among participants experiencing homelessness compared to 1,769 (1,4531,453-2,085) and 1,912(1,912 (1,510-$2,314) among housed and low-income housed individuals. Participants experiencing homelessness had nearly seven times (6.90 [95% confidence interval [CI] 5.98–7.97]) the unadjusted mean ratio (MR) of costs as compared to housed persons. After adjustment for number of comorbidities and history of healthcare for mental health and substance use disorders, participants experiencing homelessness had nearly six times (adjusted MR 5.79 [95% CI 4.13–8.12]) the expected healthcare costs of housed individuals. The two housed groups had similar costs. Conclusions Homelessness is associated with substantial excess healthcare costs. Programs to quickly resolve and prevent cases of homelessness are likely to better meet the health and healthcare needs of this population while being a more efficient use of public resources.
... Although the adaption of the healthcare system to the needs of people undergoing homelessness in order to establish a continuum of care is still an urgent issue, studies on healthcare system use for in-patient treatment among homeless people are scarce and mainly come from North American countries. 15,16 A Canadian study of administrative data on admissions over a 5-year period showed that homeless patients on surgical and medical wards remained in hospital longer, resulting in substantially higher costs. 16 However, homeless patients in psychiatric care incurred higher costs that could not be explained by a prolonged length of stay. ...
... 15,16 A Canadian study of administrative data on admissions over a 5-year period showed that homeless patients on surgical and medical wards remained in hospital longer, resulting in substantially higher costs. 16 However, homeless patients in psychiatric care incurred higher costs that could not be explained by a prolonged length of stay. 16 A study assessing healthcare utilisation by 1165 people experiencing homelessness in Canada found a subset of 'high users' with frequent emergency department attendance. ...
... 16 However, homeless patients in psychiatric care incurred higher costs that could not be explained by a prolonged length of stay. 16 A study assessing healthcare utilisation by 1165 people experiencing homelessness in Canada found a subset of 'high users' with frequent emergency department attendance. 15 An analysis of New York City's public general hospitals during 1992-1993 showed an extension of 36% in duration of treatment for homeless patients compared with non-homeless patients. ...
Article
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Background Homeless patients in psychiatric hospitals are a scarcely studied and there is lack of knowledge about factors associated with homelessness and in-patient treatment. Aims To determine the change over time in the number of homeless psychiatric in-patients and to examine factors associated with homelessness. Method Retrospective data analysis of 1205 selected electronic patient files on psychiatric in-patient treatment in a university psychiatric hospital in Berlin, Germany. The rate of patients experiencing homelessness over a 13-year period (2008–2021) and the sociodemographic and clinical factors associated with homelessness are analysed over time. Results Our study revealed a 15.1% increase in the rate of homeless psychiatric in-patients over the 13-year period. Of the whole sample, 69.3% people lived in secure private housing, 15.5% were homeless and 15.1.% were housed in sociotherapeutic facilities. Homelessness was significantly associated with being male (OR = 1.76 (95% CI 1.12–2.76), born outside of Germany (OR = 2.22, 95% CI 1.47–3.34), lack of out-patient treatment (OR = 5.19, 95% CI 3.35–7.63), psychotic disorders (OR = 2.46, 95% CI 1.16–5.18), reaction to severe stress (OR = 4.19, 95% CI 1.71–10.24), personality disorders (OR = 4.98, 95% CI 1.92–12.91), drug dependency (OR = 3.47, 95% CI 1.5–8.0) and alcohol dependency (OR = 3.57, 95% CI 1.67–7.62). Conclusions The psychiatric care system is facing an increasing number of patients in precarious social situations. This should be considered in resource allocation planning in healthcare. Individual solutions for aftercare, along with supported housing, could counteract this trend.
... Many individuals experiencing homelessness suffer from a serious mental illness (SMI), a substance use disorder (SUD), or a chronic health condition (e.g., HIV/AIDS) (HUD, 2020;Levitt et al., 2009). Research also indicates that individuals experiencing homelessness utilize health care services, particularly high-cost services such as emergency department visits and psychiatric hospitalizations, more frequently than comparable individuals not experiencing homelessness (Hwang et al., 2011;Salit et al., 1998). ...
... We included seven studies examining the effect of PSH on housing stability: three RCTs (Rosenheck et al., 2003;Chung et al., 2017;Palepu et al., 2013), two systematic reviews of existing literature (Aubry et al., 2020;Baxter et al., 2019), one observational study with a comparison group (Hwang et al., 2011), and one observational study without a comparison group (Hunter et al., 2017). All three studies that evaluated the At Home/Chez Soi demonstration project, a HF program in Canada for people with homelessness and a SMI, concluded that HF participants spent statistically significantly more time in stable housing than comparison participants (Aubry et al., 2015;Chung et al., 2017;Palepu et al., 2013). ...
... Hwang and colleagues (2011) similarly observed that within a six-month period, PSH participants spent more days stably housed than the TAU group. However, both groups experienced significant improvements in residential stability during the follow-up period (Hwang et al., 2011). The findings from these studies overwhelmingly support the conclusion that PSH helps individuals experiencing homelessness remain stably housed. ...
Article
In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007-2017) from the NY/NY III evaluation team, to analyze this program's impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.
... This scholarship unequivocally demonstrates that homelessness is associated with poor physical and mental health. 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). ...
... These explanations complement other research documenting high healthcare use by unhoused patients that suggest hospitals should develop discharge policies specific to the needs of unhoused patients (e.g. streamlined care coordination, intensive case management, etc.) (Hwang et al., 2011). Furthermore, we suggest such approaches must be integrated into a holistic service delivery model for unhoused patients discharged from general medicine, one that includes social service providers within the discharge discussions and in developing the discharge plan. ...
... The hospital discharge process is meant to be an effective part of a patient's continuity of care and transition to the community (Lamanna et al., 2018). It has an important role in stabilizing and improving the health of individuals, and thereby has the potential to reduce hospital readmissions (Hwang et al., 2011;Wang et al., 2021). Experiences of homelessness challenge standard discharge care, suggesting the need for a new approach to discharge for this patient population. ...
Article
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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.
... The elevated costs are partly explained by the length of stay, which is generally prolonged due to the mental health problems these patients have (7). Yet, an important share of the higher costs could not be explained by a prolonged length of stay alone (8). Disease severity at admission reflecting the limited availability of community mental health services is most probably the main reason of higher financial costs (8). ...
... Yet, an important share of the higher costs could not be explained by a prolonged length of stay alone (8). Disease severity at admission reflecting the limited availability of community mental health services is most probably the main reason of higher financial costs (8). ...
Article
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Homelessness in psychiatric patients in Flanders, Belgium, has never been investigated. Advocacy groups from patients with lived experience of psychiatric disorders have sounded the alarm on the scarcity of suitable housing options, the strain on psychiatric institutions, and the challenges faced by social service workers. To investigate the extent of the problem a survey on the topic was initiated. A “homelessness-in-mental-health-questionnaire” was designed by experts in the field. The social services of all Flemish psychiatric hospitals and all psychiatric wards in general hospitals were contacted and invited to complete this survey. 24 of 70 contacted services responded. The total number of homeless patients in the inpatient setting on an annual basis are estimated to an average 19.5%. 18% of homeless patients remain longer in admission due to the lack of housing options. 13.7% of homeless psychiatric patients are referred to a community care facility such as an assisted living facility. Social service respondents reported spending an average of 27.4% of their work time on housing issues. The main focus points according to the respondents are the lack of priority measures for homeless psychiatric patients, psychiatric problems as a barrier to housing options and the shortage of adapted housing capacity. The conclusion of this study is the need for comprehensive policy interventions to ensure an adequate supply of suitable social housing for psychiatric patients, accessible mental health care, alternative housing options and crisis accommodation facilities. We propose a 10-point action plan on housing for psychiatric patients for policymakers and politicians.
... Four primary studies 36,47,54,55 reported that the average age of PEH was younger than that of individuals with housing for similar disease processes, and another primary study 38 reported fewer elderly PEH. Four primary studies 47,56-58 also reported that PEH were more likely to be from racialized groups, including Black, Hispanic, and Native American. ...
... 117 The majority of com ments presented concerns regarding living conditions. The lack of stable housing was described as a possible reason for leaving against medical advice, 57 readmis sion, 54,92 extended hospital stay, 55,58,67,87,93,94 and missing followup appointments. 36,64,79,[95][96][97] In addition, authors commented on how the lack of a regular address leaves home nursing services inaccessible, 97 terminal care impossible, 49 and deters patients from pro cedures. ...
Article
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Background: Numerous studies have highlighted the inequitable access to medical and psychiatric care that people experiencing homelessness (PEH) face, yet the surgical needs of this population are not well understood. We sought to assess evidence describing surgical care for PEH and to perform a thematic analysis of the results. Methods: Ovid MEDLINE, Embase, and Web of Science were searched using the terms "surgery" AND "homelessness." Grey literature was also searched. We used a stepwise scoping review methodology, followed by thematic analysis using an inductive approach. Results: We included 104 articles in our review. Studies were included from 5 continents; 63% originated in the United States. All surgical specialties were represented with varying surgical conditions and procedures for each. Orthopedic surgery (21%) was the most frequently reported specialty. Themes identified included characteristics of PEH receiving surgical care, homeless-to-housed participants, interaction with the health care system, educational initiatives, barriers and challenges, and interventions and future strategies. Conclusion: We identified significant variation and gaps, representing opportunities for further research and interventions. Further addressing the barriers and challenges that PEH face when accessing surgical care can better address the needs of this population.
... Hospital admissions for patients experiencing homelessness on average last five times longer than lowincome patients [24,25]. One study found that ICU hospital days, acute care days and costs were substantially greater among the homeless population compared to the stable housed population [26]. Approximately one in every three hospitalizations of patients experiencing homelessness had an intensive care unit (ICU) admission, which is much greater than the rate of ICU admission among those with stable housing [22,[27][28][29]. ...
... This is supported by the higher healthcare resource use during and after critical illness among patients experiencing homelessness compared to patients with stable illnesses that would be suitable for management utilizing preventative care [41,[44][45][46]. It has been found that patients experiencing homelessness have heightened care intensity and longer hospital stays resulting in an increased cost of $2559-$2907 per hospital admission when compared to patients that are stably housed of similar age and sex [4,22,25,26,47]. In addition to increased use of emergency department and acute care, there exists a high utilization of critical care resources among those experiencing homelessness [23], which is supported by the finding that patients experiencing homelessness used more invasive mechanical ventilation. ...
Article
Full-text available
Purpose To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing. Methods This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status. Results 2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0–2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8–2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6–11.6, p < 0.001), compared with those who have stable housing. Conclusions Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-023-04753-7.
... [1][2][3][4] In addition, individuals experiencing homelessness have a higher utilization of urgent health care services, contributing to increased costs for health care delivery systems. [5][6][7][8] US health care delivery system efforts to address housing instability have increased in recent years, including referrals and interventions in health care settings, [9][10][11] social service delivery through Medicaid Accountable Care Organizations, 12 and Medicaid reimbursement for Permanent Supportive Housing. 13 However, few health care systems have instituted a general screening for homelessness and housing instability or have pragmatic assessment tools to identify patients at risk. ...
... Knowing which patients in an integrated health care system are at an increased chance of developing homelessness in the next 1-2 years could serve as an initial triage step to enhance screening and referral tools for addressing homelessness, which can ultimately improve health outcomes, [1][2][3][4] reduce health care costs, [5][6][7][8] and effectively utilize limited health care system resources. This study's objective was to identify which individual-level characteristics available in EHRs predicted the chance of experiencing homelessness in the next 1-2 years. ...
Article
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Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors’ objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or “homeless/shelter” in address name). The predictors were measured in 2018–2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.
... As a consequence, people experiencing homelessness are often overrepresented in acute healthcare services including A&E, ambulance services, and as hospital inpatients. The extant research shows that these factors translate to a significant financial burden on the Australian healthcare system Zaretzky et al., 2008;Poulin et al., 2010;Hwang et al., 2011;Hwang et al., 2013;Wood et al., 2016;Parsell, et al., 2017;Vallesi et al., 2020). ...
... Among rough sleepers in this group of healthcare users (i.e., those with more than one healthcare occurrence in the specified category), the mean cost for each service type are: These findings are in line with previous studies showing that a small number of people experiencing homelessness, particularly those sleeping rough, incur much higher healthcare costs than the majority of the homeless population (Hwang et al., 2011;Fuehrlein et al., 2014;Zaretzky et al., 2017). ...
Technical Report
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The objectives of this report are twofold. First, to collate and assess the current evidence base on the state of homelessness in Australia and its key drivers. Second, to set out an evidence-informed policy and practice agenda towards ending homelessness in Australia. Our examination of the current state of homelessness draws on publicly available Australian Census and Specialist Homelessness Services Collection (SHSC) data and national data sources on the drivers of homelessness. The report also presents the first detailed examination of the consolidated national Advance to Zero database for the decade 2010-2020. The Advance to Zero database is a community organisation led and controlled database built on advance to zero homelessness projects (the Zero Projects). The Advance to Zero database includes responses to the Vulnerability Index – Service Prioritisation Decision Assistance Tool (VI-SPDAT) from those experiencing homelessness (particularly those who are sleeping rough and in homelessness service supported accommodation) as well as information on the journeys from homelessness to housing as mapped by homelessness services. The VI-SPDAT provides services on the ground with a comprehensive assessment of health and social needs. The Australian Advance to Zero database provides a rich platform from which to understand the circumstances of Australians experiencing homelessness and, in particular, those experiencing rough sleeping and in homelessness services supported accommodation in Australia’s cities and regional towns.
... A digital platform that algorithmically matches patients experiencing homelessness to appropriate shelters that are most likely to have availability on a certain day and at a certain time could decrease the time and effort on behalf of ED social workers as well as the patient's length of stay in the hospital. Research has shown that PEH are at high risk of returning to the emergency department [21,32]. Therefore, efforts to prioritize the placement of patients based on "vulnerability"-a concept raised by both our social workers and case managers during our interviews-are important to highlight. ...
Article
Full-text available
People experiencing homelessness are more likely to utilize emergency departments than their non-homeless counterparts. However, obtaining a bed in a homeless shelter for patients can be complex. To better understand the challenges of finding a safe discharge plan for homeless patients in the emergency department, our team conducted interviews with emergency department social workers and homeless shelter case managers in the Boston area. We identified and mapped the stages in the processes performed by both parties, identifying challenges with successful placement into a shelter. Furthermore, we assembled a data dictionary of key factors considered when assessing a patient’s fit for a homeless shelter. By identifying bottlenecks and areas of opportunity, this study serves as a first step in enabling homeless individuals to receive the post-discharge assistance they require.
... Le taux de consommation de substances est disproportionnellement élevé chez les personnes en situation d'itinérance, et celles-ci présentent un risque plus élevé de méfaits liés à la consommation de substances par rapport aux personnes ayant un logement [3][4][5][6][7] . Les personnes sans abri sont également plus susceptibles que les personnes ayant un logement de recevoir un diagnostic de trouble de santé mentale, de rester hospitalisées plus longtemps et d'être réadmises dans les 30 jours suivant leur sortie [4][5][6][7][8][9] . ...
Article
Introduction L’objectif de cette analyse est de décrire les caractéristiques démographiques du patient, le contexte, les caractéristiques et les conséquences de l’intoxication liée à la consommation de substances ainsi que les troubles de santé mentale consignés chez les personnes ayant un logement et chez celles en situation d’itinérance. Méthodologie Les données sur l’hospitalisation au Canada (à l’exclusion du Québec) du 1er avril 2019 au 31 mars 2020 ont été extraites de la Base de données sur les congés des patients de l’Institut canadien d’information sur la santé (ICIS) à l’aide des codes de la CIM-10-CA pour jusqu’à 25 diagnostics d’intoxication liée à la consommation de substances, l’itinérance et d’autres caractéristiques ayant trait à l’hospitalisation du patient. À l’aide du test du khi carré, de tests t et de la méthode exacte de Fisher, nous avons comparé les caractéristiques des personnes en situation d’itinérance à celles des personnes ayant un logement ainsi que les caractéristiques de leur hospitalisation pour intoxication liée à la consommation de substances. Résultats La proportion d’hommes, de jeunes et de personnes ayant des troubles de santé mentale consignés était plus forte chez les personnes en situation d’itinérance hospitalisées pour une intoxication liée à la consommation de substances que chez leurs homologues ayant un logement. Les intoxications liées à la consommation de substances chez les personnes en situation d’itinérance étaient plus susceptibles d’être accidentelles, d’être causées par des opioïdes et des stimulants (le plus souvent le fentanyl et ses analogues ainsi que l’héroïne), d’entraîner une hospitalisation plus longue et de se conclure par un départ de l’hôpital contre l’avis du médecin. Conclusion Ces résultats sont utilisables pour renforcer les stratégies et les interventions visant à réduire les méfaits liés à la consommation de substances dans les populations prioritaires, en particulier les personnes en situation d’itinérance.
... Type of homelessness also affects service use patterns, with people experiencing unsheltered homelessness accessing fewer primary and preventative health services than those residing in shelters (Richards and Kuhn, 2023). Ultimately, this may result in higher healthcare costs due to health deteriorations that require longer hospital admissions when care is eventually accessed (Hwang et al., 2011). Anti-homelessness ordinances and architecture are additional burdens that disproportionally affect people experiencing unsheltered homelessness by restricting access to sleeping locations and undermining safety. ...
Article
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Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff.
... Despite higher ED use and need for care, abstinencebased drug policies and poor pain management protocols contribute to marginalized populations leaving the hospital on their own decision, cyclically resulting in treatment delays and increased mortality risk [17][18][19]. Length of stay is often higher for unhoused populations as a result of long wait times to secure a shelter bed and discharge policies that are not designed for patients without a fixed address [20]. This dynamic is playing out on the backdrop of discrimination and stigma [21][22][23] that manifest at the interpersonal (e.g., provider and patient interactions), organizational (e.g., institutional policies), and structural levels (e.g., laws). ...
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Background People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer. Methods Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data. Results Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department. Conclusions The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.
... In addition, the psychosocial complexities that underlie their health problems often remain unaddressed in hospital, and they are discharged into the same conditions that contributed to their initial presentation (Canham et al., 2019). Lack of post-discharge supports for PWLEH lead to recurrent readmissions and increased overall healthcare costs (Hwang et al., 2011;Kiran et al., 2020;McCormick & White, 2016;Mcghie et al., 2013;Salit et al., 1998). ...
... Once admitted to hospital this population often requires more specialized care and longer lengths of stay largely attributable to illness severity and psychosocial needs [14,15] resulting in increased costs. For example, homeless patient admissions on the psychiatric service at a Toronto, Canada hospital cost $1058 more than housed patient admissions, even after adjusting for length of stay [16]. Moreover, individual recovery and social reintegration are challenging for the majority of individuals following discharge and are often complicated by poor access to treatment and support services resulting in substantial unmet needs [17]. ...
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Background A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital. Methods A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression. Results The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period. Conclusions Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed. Question Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission? Findings In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission. Meaning Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission.
... The consumption of alcohol as a dependent variable and its relationship with a range of factors mentioned above and shown in Table 1 care costs (Macias et al., 2014) and the mortality rate among these individuals is three to five times higher than in the general population (Hwang et al., 2011). Previous studies on the Spanish homelessness population suggested that alcohol-related problems preceded homelessness (Panadero et al., 2017;Roca et al., 2019). ...
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This article uses the latest Spanish Survey on Homeless People to address whether traumatic experiences, sociodemographic characteristics, and homeless categories are associated with being an abstainer, a risky drinker, or a high-risk drinker. The sample was composed of 3,407 Spanish homeless adults ranging from 18 to 93 years old ( M age = 41.30, SD = 13.86). A multinomial logistic regression model was used. Results showed that experiencing childhood problems and demographic factors, such as being male, single, over 50, living in insecure or inadequate housing, and having lived in a shelter for less than three months were associated with alcohol consumption. Likewise, traumatic life events, such as a parent having been in prison, illness, disabilities, and alcohol problems in the family or themselves, are also risk factors in alcohol use. The findings from Spain support that early intervention strategies both disrupt cumulative inequality and empower those at risk of homelessness to develop their skills and improve their wellbeing.
... Despite their documented high morbidity and mortality rates, people experiencing homelessness encounter frequent barriers when accessing health and social services, such as competing needs, inaccessibility, concerns about safety and care quality, and lack of continuity of care (5)(6)(7)(8). These barriers can cause people experiencing homelessness to prematurely disengage from services or to use more accessible but more costly acute care services that do not effectively meet their complex support needs (6,9). ...
Article
Objective: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto. Methods: The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest. Results: No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period. Conclusions: In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.
... Frequent ED presentation and re-presentation by patients experiencing homelessness puts pressure on ED capacity and has an enormous price tag for the health system [21,24]. It is not surprising therefore, that people experiencing homelessness often present to ED with health issues that have escalated due to barriers to accessing far lower cost primary care and prevention [8,25]. Complex intersecting needs further complicate the ED presentations of people experiencing homelessness-these commonly include combinations of acute and chronic health issues, mental health, and substance use issues, along with significant social concerns which, obviously, include the lack of a safe place to stay. ...
Article
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The ED is often the first and sometimes the only place where people experiencing home-lessness seek medical assistance. While access to primary healthcare is a preferable and more cost-effective alternative to ED, for many reasons, people experiencing homelessness are much less likely to have a regular General Practitioner compared to those living in stable accommodation. Drawing on a growing body of emergency care and homelessness literature and practice, we have synthesised four potential interventions to optimise access to care when people experiencing home-lessness present to an ED. Although EDs are in no way responsible for resolving the complex health and social issues of their local homeless population, they are a common contact point and therefore present an opportunity to improve access to healthcare.
... The J2SI research study measures changes across a number of domains of social and economic wellbeing. In addition to a compromised quality of life among individuals experiencing homelessness, there is a wealth of evidence that systems of service delivery, including the health, justice, and welfare systems, incur substantial costs as a result of homelessness Poulin et al. 2010;Hwang et al. 2011;Hwang et al. 2013;Zaretzky et al. 2013;Wood et al. 2016;Parsell, Petersen, & Culhane, 2016;Zaretzky et al. 2017). Examination of both individual and system effects serves to both improve understanding of the journeys of individuals who experience chronic homelessness and to evaluate the full impact of the J2SI Phase 2 program on its participants and broader social systems. ...
Technical Report
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Sacred Heart Mission (SHM)’s Journey to Social Inclusion (J2SI) Phase 2 program began in January 2016 and ended in September 2019. Building on the strong housing outcomes of the J2SI pilot program, the J2SI Phase 2 program aimed to address chronic homelessness in Melbourne by facilitating rapid access to housing and sustaining that housing over time. In addition, the J2SI program sought improved health and wellbeing outcomes, increased social and economic participation, and increased capacity for independence. In short, the J2SI Phase 2 program aimed to improve social inclusion outcomes for those experiencing chronic homelessness. This report presents the outcomes achieved by participants in the J2SI Phase 2 research study over the 2016-2019 time period. The report also presents an economic analysis of the J2SI Phase 2 program, comparing the cost of delivering the program against the impact of the program on government costs arising from participant interaction with the health and justice systems.
... Conversely, the few patients in our cohort experiencing homelessness prior to admission were less likely to have PLOS. This is counter to the observation that patients without stable housing typically have longer LOS [29]. This difference may be in part due to the establishment of respite and quarantine locations for this population at the height of the pandemic and a robust and integrated healthcare system in Boston for patients experiencing homelessness [30]. ...
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Background During the initial surge of coronavirus disease 2019 (COVID-19), healthcare utilization fluctuated dramatically, straining acute hospital capacity across the United States (US), and potentially contributing to excess mortality. Methods This was an observational retrospective study of patients with COVID-19 admitted to a large US urban academic medical center during a twelve-week COVID-19 surge in the Spring of 2020. We describe patterns in length of stay (LOS) over time. Our outcome of interest was prolonged length of stay (PLOS) which we defined as seven or more days. We performed univariate analyses of patient characteristics, clinical outcomes, and discharge disposition to evaluate the association of each variable with PLOS and developed a final multivariate model via backward elimination wherein all variables with a p-value above 0.05 were eliminated in a stepwise fashion. Results The cohort included 1,366 patients, of whom 13% died and 29% were readmitted within 30 days. LOS (mean: 12.6) fell over time (p<0.0001). Predictors of PLOS included discharge to a post-acute care (PAC) facility (odds ratio [OR]: 11.9, 95% confidence interval [CI] 2.6-54.0), uninsured status (OR 3.2, CI 1.1-9.1), and requiring intensive care and intubation (OR 18.4, CI 11.5-29.6). Patients had a higher readmission rate if discharged to PAC facilities (40%) or home with home health agency (HHA) (38%) services as compared to patients discharged home without HHA (26%) (p<0.0001). Conclusion Patients hospitalized with COVID-19 during a US COVID-19 surge had a prolonged LOS and high readmission rate. Lack of insurance, an ICU stay, and a decision to discharge to a PAC facility were associated with a PLOS. Efforts to decrease LOS and optimize hospital capacity during COVID-19 surges may benefit from focusing on increasing PAC and HHA capacity and resources.
... First, the population health of people experiencing homelessness is limited by their high rates of physical and mental health conditions, which contribute to high morbidity and mortality rates (Aldridge et al., 2018;Fazel et al., 2014;Gutwinski et al., 2021;Roncarati et al., 2018). Second, there are many barriers to people experiencing homelessness obtaining timely and appropriate healthcare, resulting in greater costs from higher use of acute services and more severe symptoms at the point of service contact (Canavan et al., 2012;Hwang et al., 2011;Krausz et al., 2013). Third, negative experiences using healthcare services are common among the homeless population, which can lead to service avoidance and more unmet health needs (Allen & Vottero, 2020;Kerman & Sylvestre, 2021;Kerman et al., 2019;Omerov et al., 2020). ...
Article
The Quadruple Aim is a health policy framework with the objective of concurrently improving population health, enhancing the service experience, reducing costs and improving the work‐life of service providers. Permanent supportive housing (PSH) is a best practice approach for stably housing people experiencing homelessness who have diverse support needs. Despite the intervention's strong evidence base, little is known about the work‐life of PSH providers. This study explored the mental health and work challenges experienced by PSH providers in Canada. Using an explanatory sequential, equally weighted, mixed methods design, 130 PSH providers were surveyed, followed by semi‐structured interviews with 18 providers. Quantitative findings showed that 23.1% of PSH providers had high psychological distress. Participants who were younger, spent all or almost all of their time in direct contact with service users and had less social support from coworkers were significantly more likely to have high psychological distress. Three themes were identified from the qualitative analysis that showed how PSH providers experience psychological distress from work‐related challenges: (a) Sisyphean Endeavours: ‘You Do What You Can’, (b) Occupationally Unsupported: ‘Everyone Is Stuck in Their Zone’ and (c) Wear and Tear of ‘Continuous Exposure to Crisis and Chaos’. The themes interacted with systemic (Sisyphean Endeavours) and organisational issues (Occupationally Unsupported), intensifying the emotional burden of day‐to‐day work, which involved frequent crises and uncertainty (Wear and Tear of ‘Continuous Exposure to Crisis and Chaos’). The findings underscore how these challenges threaten providers' wellness at work and have implications for the care provided to service users. Accordingly, the Quadruple Aim is a potentially useful and applicable framework for measuring the performance of PSH programs, which warrants further consideration in research and policy.
... 8 Individuals who experience homelessness not only have higher rates of hospital admission, but they also have longer stays once admitted-at least 2 days longer for acute admissions. 9 While primary care access was reported more than expected, many still lacked consistent care. A lack of regular primary care may contribute to the overutilization of EDs, leading to poor outcomes and experiences for both patients and clinicians. ...
Article
Background: This project aims to assess the needs and barriers to care from the people experiencing homelessness in a large Midwestern city from their perspective. Methods: This survey was advised by those with lived experience of homelessness and those who work in the space. Surveys were disseminated during outreach around the city of Milwaukee, Wisconsin. Data were transcribed, reviewed, and analyzed. Results: Results indicated that 68% of participants perceive their health as "poor" or "fair." Fifty-five percent indicated they had primary care, and 64% reported possessing active health care insurance. There were many perceived barriers to care including lack of transportation, money, and inadequate clinic hours. Conclusions: Survey results indicate that the needs and barriers to care for those experiencing homelessness are broad and complex and should be factored when considering solutions and aiming to provide more equitable care.
... al. found that homelessness was associated with increased cost of admission for surgical interventions in Canadian hospitals; however, this difference was not statistically significant, unlike the difference in inpatient stays for medical interventions. 32 A 2019 study in the U.S. found that homeless patients undergoing emergency general surgery and living in non-Medicaid expansion states had higher charges, increased mortality, and more surgical complications. 39 There was only one publication that focused on mortality differences between homeless and housed populations following surgery, finding that homeless adults with ST-elevation myocardial infarction or stroke had a higher risk-standardized mortality than non-homeless persons and were less likely to undergo percutaneous coronary angiography or intervention and coronary artery bypass grafting. ...
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.
... A study conducted in the pre-COVID-19 era found that the average cost of a hospitalization was approximately $1000 higher among individuals experiencing homelessness than among housed people. 38 We found that the mean net cost for individuals experiencing homelessness with COVID-19 was approximately $500 higher than among all community-dwelling cases and $1500 higher than among all LTC residents. Our findings are consistent with others that, taken together, highlight the importance of addressing homelessness as one facet of marginalization. ...
Article
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Objectives Local health leaders and the Director General of the World Health Organization alike have observed that COVID-19 “does not discriminate.” Nevertheless, the disproportionate representation of people of low socioeconomic status among those infected resembles discrimination. This population-based retrospective cohort study examined COVID-19 case counts and publicly funded healthcare costs in Ontario, Canada, with a focus on marginalization. Methods Individuals with their first positive severe acute respiratory syndrome coronavirus 2 test from January 1, 2020 to June 30, 2020, were linked to administrative databases and matched to negative/untested controls. Mean net (COVID-19–attributable) costs were estimated for 30 days before and after diagnosis, and differences among strata of age, sex, comorbidity, and measures of marginalization were assessed using analysis of variance tests. Results We included 28 893 COVID-19 cases (mean age 54 years, 56% female). Most cases remained in the community (20 545, 71.1%) or in long-term care facilities (4478, 15.5%), whereas 944 (3.3%) and 2926 (10.1%) were hospitalized, with and without intensive care unit, respectively. Case counts were skewed across marginalization strata with 2 to 7 times more cases in neighborhoods with low income, high material deprivation, and highest ethnic concentration. Mean net costs after diagnosis were higher for males (4752vs4752 vs 2520 for females) and for cases with higher comorbidity (13941394-7751) (both P < .001) but were similar across levels of most marginalization dimensions (range 32323232-3737, all P ≥ .19). Conclusions This study suggests that allocating resources unequally to marginalized individuals may improve equality in outcomes. It highlights the importance of reducing risk of COVID-19 infection among marginalized individuals to reduce overall costs and increase system capacity.
... Poor health outcomes, coupled with access and price barriers associated with accessing preventative healthcare services translate to high rates of people experiencing homelessness utilising acute public healthcare services (ambulance, hospital and accident and emergency departments); notwithstanding this, there is a high degree of variation in healthcare utilisation reflecting varying levels of health needs and opportunities for access among those experiencing homelessness (Flatau & Zaretzky, 2008;Hwang et al., 2011;Lin et al., 2015;Parsell et al., 2016;Rieke et al., 2015;Wood et al., 2016;Zaretzky et al., 2013Zaretzky et al., , 2017. As a result, it is widely understood that homelessness, particularly rough sleeping, leads to high health costs. ...
Article
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This study seeks to assess the health, social and economic outcomes associated with rough sleeping among women and compare those outcomes with those of (1) men sleeping rough, and (2) women experiencing other forms of homelessness (such as being housed in temporary supported accommodation due to family and domestic violence). The paper analyses survey data using the Vulnerability Index‐Service Prioritization Decision Analysis Tool (VI‐SPDAT) collected from 2735 women experiencing homelessness and 3124 men sleeping rough in Australian cities from 2010 to 2017. We find that women sleeping rough report poorer physical and mental health outcomes and greater problematic drug and or alcohol use relative to both men sleeping rough and women experiencing other types of homelessness (all p < 0.5). Women sleeping rough report significantly higher levels of crisis service utilisation (Β = 17.9, SE = 3.9, p < 0.001) and interactions with police in the previous 6 months (Β = 1.9, SE = 0.3, p < 0.001) than women experiencing homelessness not sleeping rough. Women sleeping rough also report greater healthcare utilisation, and, therefore, healthcare costs, than women experiencing homelessness not sleeping rough and men sleeping rough (all p < 0.05). From a policy perspective, the evidence presented in this paper supports a social determinants approach that moves from addressing symptoms of poor health outcomes associated with homelessness to preventing and ending homelessness with a particular focus on the life trajectories of women. Integrated services and homelessness strategies need to be developed through a gender lens, providing women sleeping rough with tailored permanent housing with wrap‐around supportive housing to address poor health outcomes.
Article
Objective To examine the association between housing status and healthcare utilization in individuals presenting with seizure. Methods We performed a retrospective cross-sectional analysis of all adults (age >18) presenting to a public hospital emergency department with seizures, defined by ICD-9/10 codes, between 1/1/2016 and 8/03/2019. They were categorized by housing status (people experiencing homelessness [PEH], people with housing). Healthcare utilization outcomes were 30-day re-visit to acute care, discharge disposition, and hospital length of stay for those admitted. We used multivariable linear and logistic regression models adjusting for age, comorbidities, and insurance status. Results There were 6483 individuals (2092 [32.3%] PEH). Compared to people with housing, PEH were younger (48.2 vs 50.9, P < .0001), more likely to be a person of color (80.9 vs 75.1%, P < .0001), and have Medicaid (51.4% vs 42.9%, P < .0001). People with housing had a higher prevalence of admission to the intensive care unit (3.6% vs 1.8%, P < .0001). After adjustment, admitted PEH had higher odds of 30-day re-visit (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.58, 2.21), shorter length of stay (coef Β-12.87, 95% CI: −22.62, −3.11), and lower odds of being discharged to a facility (aOR 0.37, 95% CI: .26, .55) compared to people with housing. Conclusion and Relevance PEH with seizures had increased healthcare utilization. Further analysis, including imaging findings, anti-seizure medications prescribed, and presumed etiology, is needed to understand the drivers of healthcare utilization and identify appropriate interventions.
Article
Unhoused (UH) individuals experience burn injuries at a higher rate than domiciled individuals, and have poorer outcomes following injuries. One such mechanism proposed for worsened outcomes is secondary to poor nutrition. Access to proper nutrition and food insecurity are major barriers. Malnutrition has been shown to decrease wound tensile strength, increase infection rates, and prolong healing. The purpose of this study was to understand if albumin and prealbumin could help determine outcomes in UH patients and identify at-risk patients earlier in their hospital course A retrospective chart review was conducted of UH patients from 2015 through 2023 at a large urban safety net hospital. Data collected included admission laboratory values including albumin and prealbumin. Outcomes studied included length of stay, ICU days, ventilator days, and mortality. Data analysis for the effect of albumin and prealbumin included a zero-truncated negative binomial model for length of stay, a negative binomial hurdle model for ICU length of stay and ventilator days, and logistic regression for mortality. 385 patients met inclusion criteria and of these, 366 had albumin and 361 had prealbumin information. Adjusting for age, gender, and TBSA, the fewest days in the hospital and lowest odds of admission to the ICU occurred for those with admission albumin values of approximately 3.4-3.5 g/dL. Each unit (g/dL) decrease in albumin was associated with 3.19 times the odds of death (95% CI 1.42, 7.69). Each unit (mg/dL) decrease in prealbumin was associated with 1.19 times the odds of death (95% CI 1.06, 1.35). Decreased admission albumin and prealbumin levels are associated with worse burn outcomes in UH patients. These nutritional biomarkers may aid in determining which UH patients are suffering from food insecurity at injury onset. Obtaining these values on admission may help burn providers target nutritional goals in their most vulnerable patients.
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Objectives To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. Design Retrospective cohort study. Setting Mariner claims database. Patients/Participants Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. Intervention Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. Main Outcome Measures One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. Results Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08–2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08–1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00–1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59–0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63–1.18, P = 0.41). Conclusions Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. Level of Evidence Prognostic Level III.
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Introduction The objective of this analysis is to describe patient demographics, the context, characteristics and outcomes of a substance-related poisoning, and the recorded mental disorder of people with housing and those experiencing homelessness. Methods Hospitalization data for Canada (except Quebec) from 1 April 2019 to 31 March 2020 were retrieved from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database using ICD-10-CA codes for up to 25 diagnoses for substance-related poisonings, homelessness status and other characteristics relevant to the patient’s hospitalization. We compared the characteristics of people experiencing homelessness with those of people who were housed, and their substance-related poisoning hospitalizations, using chi-square, t tests and Fisher exact test. Results There was a higher proportion of males, younger individuals and people with recorded mental disorders among people experiencing homelessness hospitalized for a substance-related poisoning than among their housed counterparts. Substance-related poisonings among people experiencing homelessness were more likely to be accidental, involve opioids and stimulants (most frequently fentanyl and its analogues and heroin), result in lengthier hospitalizations and end with leaving the hospital against medical advice. Conclusion These findings can be used to strengthen strategies and interventions to reduce substance-related harms in priority populations, particularly those experiencing homelessness.
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Importance Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures People experiencing homelessness were identified using the TQP’s alternate home residence variable. Main Outcomes and Measures Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients ( P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.
Article
Access to safe and stable housing has both a direct and indirect effect on health. Experiencing homelessness and housing instability can induce stress and trauma, worsening behavioral health and substance use. The absence of safe and stable living conditions can make it challenging to rest, recuperate, and recover from health ailments and can pose barriers to treatment adherence. Homelessness and housing instability is associated with high rates of numerous diseases and chronic conditions. Its cyclical relationship with other social drivers of health can exacerbate health disparities. As a result, unhoused persons experience unique health challenges and require a health care system and professionals designed to meet their distinct needs. Physicians and other health professionals have a role in educating themselves about the needs of unhoused patients as well as making themselves aware of community and government resources available to these populations. Policymakers must support health professionals in these efforts by supporting the data infrastructure needed to facilitate these referrals to resources, supporting research into best practices for caring for these populations, and investing in community-based organization capacity. Policy action is needed to address the underlying drivers of homelessness, including a dearth of affordable housing, while also addressing the short-term need for safe shelter now. In this position paper, the American College of Physicians (ACP) recognizes the need to address universal access to housing to fulfill one's right to health. ACP offers several recommendations to prevent homelessness and promote the necessary health care and social needs of unhoused populations.
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Background Efficiently identifying the social risks of patients with serious illnesses (SIs) is the critical first step in providing patient-centered and value-driven care for this medically vulnerable population. Objective To apply and further hone an existing natural language process (NLP) algorithm that identifies patients who are homeless/at risk of homeless to a SI population. Methods Patients diagnosed with SI between 2019 and 2020 were identified using an adapted list of diagnosis codes from the Center for Advance Palliative Care from the Kaiser Permanente Southern California electronic health record. Clinical notes associated with medical encounters within 6 months before and after the diagnosis date were processed by a previously developed NLP algorithm to identify patients who were homeless/at risk of homelessness. To improve the generalizability to the SI population, the algorithm was refined by multiple iterations of chart review and adjudication. The updated algorithm was then applied to the SI population. Results Among 206 993 patients with a SI diagnosis, 1737 (0.84%) were identified as homeless/at risk of homelessness. These patients were more likely to be male (51.1%), age among 45-64 years (44.7%), and have one or more emergency visit (65.8%) within a year of their diagnosis date. Validation of the updated algorithm yielded a sensitivity of 100.0% and a positive predictive value of 93.8%. Conclusions The improved NLP algorithm effectively identified patients with SI who were homeless/at risk of homelessness and can be used to target interventions for this vulnerable group.
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The “No Fixed Address” version 2 (NFAv.2) project tested the efficacy of a potential best practice program that aimed to prevent discharge from hospital into homelessness. Forchuk and colleagues developed a system that streamlined housing and social supports using on-site access to help inpatients in a psychiatric unit who were homeless or at-risk of homelessness find safe, affordable housing. A total of 370 individuals accessed the NFAv.2 program between August 2017 and May 2020. Of these, 88 participants who accessed the intervention were enrolled in the evaluation of the project. Information on housing history and housing outcomes were collected during hospital admission and at 3-time points post-discharge. Focus groups were conducted for program participants, health care staff, and community partners to gather information regarding their experiences with the program. Of those who participated in the intervention, 80% were housed and remained housed at 12 months post-discharge. Results from focus groups also indicated that the majority of NFAv.2 clients, staff, and community partners were satisfied with the intervention. Since homelessness has a detrimental effect on recovery, client safety, and healthcare expenditures, locating safe housing has had a positive impact on treatment, rehabilitation, and the healthcare system as a whole. The findings of this project offer policy alternatives for the prevention of homelessness for at-risk individuals.
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Homelessness continues to be a major social and clinical problem. The homeless population has a higher burden of disease that includes psychiatric disorders. In addition, they have a lower use of ambulatory health services and a higher use of acute care. Few investigations analyze the use of services of this population group in the long term. We analyzed the risk of psychiatric readmission of homeless individuals through survival analysis. All admissions to a mental health hospitalization unit in the city of Malaga, Spain, from 1999 to 2005, have been analyzed. Three analyses were carried out: two intermediate analyses at 30 days and 1 year after starting follow-up; and one final analysis at 10 years. In all cases, the event was readmission to the hospitalization unit. The adjusted Hazard Ratio at 30 days, 1-year, and 10-year follow-ups were 1.387 (p = 0.027), 1.015 (p = 0.890), and 0.826 (p = 0.043), respectively. We have found an increased risk of readmission for the homeless population at 30 days and a decreased risk of readmission at 10 years. We hypothesize that this lower risk of long-term readmission may be due to the high mobility of the homeless population, its low degree of adherence to long-term mental health services, and its high mortality rate. We suggest that time-critical intervention programs in the short term could decrease the high rate of early readmission of the homeless population, and long-term interventions could link them with services and avoid its dispersion and abandonment.
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Goals: Examine outcomes among homeless patients admitted with gastrointestinal (GI) bleeding, including all-cause mortality and endoscopic intervention rates. Background: Hospitalizations among homeless individuals have increased steadily since at least 2007 but little is known about GI outcomes in these patients. Study: The 2010-2014 Healthcare Utilization Project (HCUP) State Inpatient Databases from New York and Florida were used to identify adults admitted with a primary diagnosis of acute upper or lower GI bleed. Homeless patients were 1:3 matched with nonhomeless patients using a propensity-score greedy-matched algorithm. The primary outcome (all-cause in-hospital mortality) and secondary outcomes (30-day readmission rates, endoscopy utilization, length of stay, and total hospitalization costs) were compared. Results: We matched 4074 homeless patients with 12,222 nonhomeless patients. Most hospitalizations for homeless individuals were concentrated in 113 (26.4%) of 428 hospitals. Homeless adults were more likely to be younger, male, African American or Hispanic, and on Medicaid. They experienced significantly higher odds of all-cause inpatient mortality compared with nonhomeless patients admitted with GI bleeding (OR 1.37, 95% CI 1.11-1.69). Endoscopy utilization rates were also lower for both upper (OR 0.62, 95% CI 0.55-0.71) and lower (OR 0.76, 95% CI 0.68-0.85) GI bleeding, though upper endoscopy rates within the first 24 hours were comparable (OR 1.11, 95% CI 1.00-1.23). Total hospitalization costs were lower (9,715vs.9,715 vs. 12,173, P<0.001) while 30-day all-cause readmission rates were significantly higher in the homeless group (14.9% vs. 18.4%, P<0.001). Conclusions: Homeless patients hospitalized for GI bleeding face disparities, including higher mortality rates and lower endoscopy utilization.
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Intravenous drug use (IVDU) and associated infective endocarditis (IE) has been on the rise in the US since the beginning of the opioid epidemic. IVDU-IE has high morbidity and mortality, and treatment can be lengthy. We aim to quantify the association between IVDU and length of stay (LOS) in IE patients. The National Inpatient Sample database was used to identify IE patients, which was then stratified into IVDU-IE and non-IVDU-IE groups. Weighted values of hospitalizations were used to generate national estimates. Multivariable linear and logistic regression analyses were applied to estimate the effects of IVDU on LOS. We identified 1,114,257 adult IE patients, among which 123,409 (11.1%) were IVDU-IE. Compared to non-IVDU-IE patients, IVDU-IE patients were younger, had fewer comorbidities, and had an overall longer LOS (median [interquartile range]: 10 [5-20] versus 7 [4-13] d, P < 0.001), with a greater percentage of patients with a LOS longer than 30 d (13.7% versus 5.7%, P < 0.001). After adjusting for multiple demographic and clinical factors, IVDU was independently associated with a 1.25-d increase in LOS (beta-coefficient = 1.25, 95% confidence interval [CI]: 0.95-1.54, P < 0.001) and 35% higher odds of being hospitalized for more than 30 d (odds ratio = 1.35, 95% CI: 1.27-1.44, P < 0.001). Among IE patients, being IVDU has associated with a longer LOS and a higher risk of prolonged hospital stay. Steps toward the prevention of IE in the IVDU population should be taken to avoid an undue burden on the healthcare system.
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This study aimed to describe the sociodemographic characteristics, social support received, and quality of life of chronically homeless patients with schizophrenia in China. A self-prepared sociodemographic questionnaire, the Social Support Rating Scale (SSRS), European Five-dimensional Health Scale (EQ-5D), and Eysenck Personality were administrated to 3,967 chronically homeless and 3,724 non-homeless patients from the Department of Xiangtan Fifth People's Hospital, Hunan, China, between April 2011 and October 2016. Results indicated that the homeless patients were more likely to live outside the city and be ethnic minorities compared with non-homeless patients. Although the married proportion was higher among homeless patients, they had a higher rate of being divorced or widowed. Notably, the homeless patients had higher employment rates before illness, despite significantly lower education (P < 0.001). Chronically homeless patients with schizophrenia showed a lower score in the SSRS (30.29 ± 7.34 vs. 26.16 ± 10.04, p < 0.001); they had significantly lower objective support, subject support, social support, and EQ-Visual Analog Scale, Eysenck Personality Questionnaire-Psychoticism, and Eysenck Personality-Neuroticism scores (p < 0.001). Homeless patients may be worse off, and could be assisted by providing accommodation, family intervention, medical services (such as pain medication), and other comprehensive measures.
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Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in‐reach services. Thirty participants were recruited via posters placed throughout the building and semi‐structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma‐free care. Close proximity and convenience of drop‐in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre‐existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low‐barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.
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Objectives The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises. Methods Using Walt & Gilson’s Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response. Results Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration. Conclusion The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.
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Introduction: Young adults experiencing homelessness have poorer overall health compared with the general population. However, not much is known about how health care needs may change in the transition from homelessness to supportive housing. This study utilizes the Gelberg-Andersen Behavioral Model for Vulnerable Populations to examine unmet health care needs among young adults currently experiencing homelessness and formerly homeless young adults living in supportive housing. Methods: This study includes data from 192 young adults who were either residing in a supportive housing program (n=103) or were "unhoused" (eg, residing on the street, staying in emergency shelters; n=89) in Los Angeles, CA, between 2017 and 2019. Hierarchical modeling examined unmet health care needs and factors that may enable those needs to be met, controlling for predisposing and other need factors. Results: Controlling for predisposing and other need characteristics, this study identified increased enabling factors among those residing in supportive housing, the most widely applied intervention for homelessness. Participants who resided in supportive housing were more likely to report at least 1 type of unmet need than youth who did not have access to housing. Additional findings regarding the association of enabling factors and unmet need yield mixed results based on the type of unmet need. Discussion: The acknowledgment of unmet needs may, in fact, be a byproduct of shifting priorities, which often occurs in the transition from homelessness to housing. Understanding the unmet need and health implications of this transition has relevance for practice as we work to better support formerly homeless young adults in meeting the needs that they identify.
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Objective: To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender. Data sources: California Medicaid enrollment and claims. Study design: We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visits measures and four hospitalizations measures. We compared use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates. Data collection: We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data. Principal findings: We found that homelessness was significantly associated with 0.34 more ED visits (P<0.01) and a higher likelihood of frequent ED visits (2.77 percentage points (pp), P<0.01), any ED visits due to mental health conditions (0.79 pp, P<0.01), and any ED visits due to substance use disorders (1.47 pp, P<0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (P<0.01), a higher likelihood of frequent hospitalizations (0.68 pp, P<0.01) and high frequent hospitalizations (0.28 pp, P<0.01), and a longer length of stay (0.53 days, P<0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females. Conclusions: Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH. This article is protected by copyright. All rights reserved.
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Purpose The purpose of this study is to establish empirical relationships between patient flow problems, healthcare service quality and patient satisfaction with emergency department (ED) service factors from the patient perspective. Design/methodology/approach In the overall study, of which the current investigation is a part, a mixed-method research approach was to achieve the research objectives. The results reported in this paper are based on a comprehensive questionnaire survey where a well-designed and reliable questionnaire was used to survey ED patients. This study conducted partial least squares structural equation modelling (PLS-SEM) by using Smart PLS software. Findings Results show that the respondents mostly agreed with the proposed concept of quality in ED and patients were less satisfied with ED services in general and with the internal and external environments in ED in particular. It was found that relationships between nine identified scales of patient flow problems, healthcare service quality, and patient satisfaction are significant. The findings reveal that the relationship between patient flow problems and patient satisfaction is positively mediated through healthcare service quality, which shows the predictive capability of the model, indicating high predictive relevance. Research limitations/implications This research involves a relatively small sample from a single case study. The positive relationship between patient flow problems and patient satisfaction indicate practical significance of the model for guiding to improve overall patient satisfaction. Originality/value This research, through the involvement of both hospital staff and the patient, brings out a holistic approach in terms of operational excellence in a critical unit such as the ED. The empirically established relationships form the benchmarking and guide for developing guidelines for designing policies for service improvements of ED practices.
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Globally, one of the main causes of street homelessness is the reality of chronic mental illness. In societies where mental illness is misunderstood, stigmatized, or sparsely treated, or where treatment is inaccessible for the poor, the link between street homelessness and chronic mental illness becomes even greater. This article considers the stories of specific individuals living with chronic mental illness in the City of Tshwane, South Africa, which caused them to be homeless. It also reflects on the infrastructure available to persons with chronic mental illness who are homeless, and recommends ways to scale up and replicate good practices, while transforming unutilized or ineffective infrastructure. Data were collected through drawings and naïve sketches from participants housed at a community-based health centre in Tshwane which acts as a “bridge” between mental health institutions, home and/or even the street. Ten participants voluntarily participated in the study and five in-depth interviews were held with the staff members at the centre. The insights indicated that the ripple effects of a deinstitutionalization plan for a sustainable policy package, could improve the quality of life for mentally ill homeless persons while housed in such community-based centres.
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Background Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges. Methods We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed. Results From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges. Conclusions A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.
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The principal aim of this article is to share lessons learned by the authors while conducting economic evaluations, using clinical trial data, of mental health interventions. These lessons are quite general and have clear relevance for pharmacoeconomic studies. In addition, we explore how net benefit regression can be used to enhance consideration of key issues when conducting an economic evaluation based on clinical trial data. The first study we discuss found that cost-effectiveness results varied markedly based on the choice of both the patient outcome and the willingness to pay for more of that outcome. The importance of willingness to pay was also highlighted in the results from the second study. Even with a set willingness-to-pay value, most of the time the probability that the new treatment was cost effective was not 100%. In the third study, the cost effectiveness of the new treatment varied by patient characteristics. These observations have important implications for pharmacoeconomic studies. Namely, analysts must carefully consider choice of patient outcome, willingness to pay, patient heterogeneity and the statistical uncertainty inherent in the data. Net benefit regression is a useful technique for exploring these crucial issues when undertaking an economic evaluation using patient-level data on both costs and effects.
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Homelessness is a major public health problem among persons with severe mental illness (SMI). Cost-effective programmes that address this problem are needed. To evaluate the cost-effectiveness of an assertive community treatment (ACT) programme for these persons in Baltimore, Maryland. A total of 152 homeless persons with SMI were randomly allocated to either ACT or usual services. Direct treatment costs and effectiveness, represented by days of stable housing, were assessed. Compared with usual care, ACT costs were significantly lower for mental health in-patient days and mental health emergency room care, and significantly higher for mental health out-patient visits and treatment for substance misuse. ACT patients spent 31% more days in stable housing than those receiving usual care. ACT and usual services incurred 242and242 and 415 respectively in direct treatment costs per day of stable housing, an efficiency ratio of 0.58 in favour of ACT. Patterns of care and costs varied according to race. ACT provides a cost-effective approach to reducing homelessness among persons with severe and persistent mental illnesses.
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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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Homelessness affects tens of thousands of canadians and has important health implications. Homeless people are at increased risk of dying prematurely and suffer from a wide range of health problems, including seizures, chronic obstructive pulmonary disease, musculoskeletal disorders, tuberculosis, and skin and foot problems. Homeless people also face significant barriers that impair their access to health care. More research is needed to identify better ways to deliver care to this population.
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To determine a 16-week total healthcare cost and the cost-effectiveness of short-term, lipid-lowering therapy with atorvastatin 80 mg following acute coronary syndrome (ACS) in Canada. The expected costs per patient on atorvastatin 80 mg per day and placebo were compared using clinical outcome data from the MIRACL study and cost data from the Ontario Case Costing Project and the Ontario Schedule of Benefits. The cost per event avoided was also assessed. The clinical outcomes measured included: death, cardiac arrest, non-fatal myocardial infarction (MI), fatal MI, angina pectoris, stroke, congestive heart failure, and surgical or percutaneous coronary revascularizations. All direct medical costs from the perspective of the Canadian health care system were taken into account. The total expected cost per patient was 2,590 dollars in the placebo group and 2,639 dollars in the atorvastatin group. The incremental cost of atorvastatin treatment (49.26 dollars per patient) corresponded to a cost of 1,285 dollars per event avoided. The cost savings obtained through the reduction in events offset 86% of the cost of atorvastatin treatment. Budget impact analysis revealed that increased rates of atorvastatin usage following ACS were associated with large numbers of events avoided at a small additional cost when projected to the Canadian population. In Canada, the clinical benefits of intensive short-term atorvastatin treatment administered within 96 hours after ACS were associated with a favorable cost-effectiveness ratio. The incremental cost of atorvastatin is mostly offset by savings due to the reduction in events in patients treated with atorvastatin.
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Hospitals do not routinely collect data about homelessness. The objectives of the present study were to (1) describe rate of patient reports of homelessness among inpatients at a public hospital, (2) assess the agreement between patient report of housing status on a study questionnaire with clinical and administrative data about homelessness, and (3) assess changes in housing status during hospitalization. We conducted a cross-sectional survey of inpatients at an urban public hospital to assess housing status; we then examined subjects' medical charts to assess agreement with the questionnaire on housing status. Of inpatients, 25.6% were homeless at discharge. An additional 19.4% were marginally housed. One third of homeless persons had their housing status change during their hospitalization. Administrative data identified 25.6% and physicians' notes identified 22.5% as homeless. Clinical, administrative, and survey data did not agree. Homelessness and changes in housing status are common among inpatients at an urban public hospital. Poor agreement on who is homeless limits the usefulness of data.
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Homelessness is associated with high rates of hospitalizations and age-adjusted mortality. Few studies have examined whether homeless people are admitted to the hospital at an earlier age than the general population or for different diagnoses. We compared the age at admission and the primary discharge diagnoses in a national sample of 43,868 hospitalized veterans. The difference in median age between homeless and housed inpatients ranged from 10-18 years for medical-surgical diagnoses and 3-4 years for psychiatric and substance abuse diagnoses (p#.005 for all diagnoses). Homeless veterans were more likely to have been admitted for psychiatric and substance abuse diagnoses (79.9%), compared with housed veterans (29.1%). Substance abuse and psychiatric illness account for the majority of admissions among homeless veterans. Among all diagnostic groups, homeless people were admitted at younger ages. Our findings suggest that homeless people have either a more rapid disease course, leading to earlier morbidity, or lower admission threshholds sufficient to generate hospital admission.
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A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.
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The principal aim of this article is to share lessons learned by the authors while conducting economic evaluations, using clinical trial data, of mental health interventions. These lessons are quite general and have clear relevance for pharmacoeconomic studies. In addition, we explore how net benefit regression can be used to enhance consideration of key issues when conducting an economic evaluation based on clinical trial data. The first study we discuss found that cost-effectiveness results varied markedly based on the choice of both the patient outcome and the willingness to pay for more of that outcome. The importance of willingness to pay was also highlighted in the results from the second study. Even with a set willingness-to-pay value, most of the time the probability that the new treatment was cost effective was not 100%. In the third study, the cost effectiveness of the new treatment varied by patient characteristics. These observations have important implications for pharmacoeconomic studies. Namely, analysts must carefully consider choice of patient outcome, willingness to pay, patient heterogeneity and the statistical uncertainty inherent in the data. Net benefit regression is a useful technique for exploring these crucial issues when undertaking an economic evaluation using patient-level data on both costs and effects.
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During the last decade, endovascular repair (EV) has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. This has resulted in reductions in mortality, length of stay, and major complications, including paraplegia, with the added expense of the initial endograft, subsequent surveillance, and reinterventions. The purpose of this study was to conduct an economic evaluation comparing these two methods of repair. We performed an economic comparison of EV and OSR for the treatment of BTAI using a decision tree analysis with transition points derived from our institution's experience and through a review of the literature. Over a 15-year period (1991-2006), 28 patients with BTAI were treated at our center (15 EV, 13 OSR). Costs were obtained from our hospital's case costing center, the Ontario Case Costing Initiative, Ontario's Drug Benefit Formulary, and Ontario's Schedule of Benefits for physician costs. Our center's results were then combined with those from the literature to arrive at an economic model. These combined results revealed that EV, when compared to OSR, resulted in decreased early mortality (7.2% vs 22.5%), decreased composite outcome of mortality and paraplegia (7.7% vs 27.6%) and decreased composite outcome of mortality and major complication (42.5% vs 69.8%). Patients undergoing EV also had shorter intensive care unit stays (12.2 vs 15.3 days), total hospital length of stays (22.5 vs 28.6 days), and ventilator days (8.0 vs 9.2 days). Additionally, patients undergoing EV had decreased total 1-year costs compared with OSR (70,442vs70,442 vs 72,833). EV repair of BTAIs offers a survival advantage as well as a reduction in major morbidity, including paraplegia, compared with OSR, and results in a reduction in costs at 1 year. As a result, from the cost-effectiveness point of view, EV is the DOMINANT therapy over OSR for these injuries.
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To determine the rate and estimate the cost of hospitalization in a defined urban homeless population. Retrospective chart review. Kalihi-Palama Health Clinic Health Care for the Homeless Project, Hawaii State Hospital and seven acute care hospitals in Honolulu, Hawaii. A total of 1751 homeless clients contacted between 1 December 1988 and 30 November 1990. A total of 1751 individuals were studied for an aggregate of 871.3 person-years. Five hundred sixty-four hospitalizations were identified: ninety-two to the state psychiatric hospital and 472 to acute care hospitals. The age- and sex-adjusted hospitalization rate for acute care hospitals was 542/1000 person-years (compared with the state rate of 96/1000 person-years). Homeless persons were admitted to acute care hospitals for 4766 days compared with a predicted 640 days. The age- and sex-adjusted rate of admission to the state psychiatric hospital was 105/1000 person-years (compared with the state rate of 0.8/1000 person-years). Homeless persons were admitted to the state psychiatric hospital for 3837 days compared with a predicted 139 days. Homeless individuals in this study were hospitalized in acute care and psychiatric hospitals far more frequently than were members of the general population.
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Homelessness is believed to be a cause of health problems and high medical costs, but data supporting this association have been difficult to obtain. We compared lengths of stay and reasons for hospital admission among homeless and other low-income persons in New York City to estimate the hospitalization costs associated with homelessness. We obtained hospital-discharge data on 18,864 admissions of homeless adults to New York City's public general hospitals (excluding admissions for childbirth) and 383,986 nonmaternity admissions of other low-income adults to all general hospitals in New York City during 1992 and 1993. The differences in length of stay were adjusted for diagnosis-related group, principal diagnosis, selected coexisting illnesses, and demographic characteristics. Of the admissions of homeless people, 51.5 percent were for treatment of substance abuse or mental illness, as compared with 22.8 percent for the other low-income patients, and another 19.7 percent of the admissions of homeless people were for trauma, respiratory disorders, skin disorders, and infectious diseases (excluding the acquired immunodeficiency syndrome [AIDS]), many of which are potentially preventable medical conditions. For the homeless, 80.6 percent of the admissions involved either a principal or a secondary diagnosis of substance abuse or mental illness -- roughly twice the rates for the other patients. The homeless patients stayed 4.1 days, or 36 percent, longer per admission on average than the other patients, even after adjustments were made for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The costs of the additional days per discharge averaged 4,094forpsychiatricpatients,4,094 for psychiatric patients, 3,370 for patients with AIDS, and $2,414 for all types of patients. Homelessness is associated with substantial excess costs per hospital stay in New York City. Decisions to fund housing and supportive services for the homeless should take into account the potential of these services to reduce the high costs of hospitalization in this population.
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Different types of inpatients “consume” differing amounts of hospital resources, and it is important to be able to measure these differences in resource consumption, An equitable methodology for funding hospitals must take into account differences in case mix between facilities. An ability to examine these differences in case mix and resource utilization allows hospitals to focus efforts to improve efficiency. A standardized methodology for measuring resource consumption is critical to funding and resource allocation both at a global and organizational level. This study was undertaken to determine whether or not the Canadian system for measuring resource consumption, Canadian Institute for Health Information (CIHI) RIWs™, was reflective of the relative cost differences between inpatient cases at the Greater Victoria Hospital Society (GVHS) and to identify RIWs with a significant difference in comparison to GVHS cost weights. A regression analysis was performed on the more than 30,000 inpatient cost profile records from the GVHS 1995–96 cost and patient activity data. The scope of the analysis was restricted to the 424 Case Mix Groups (CMGs) that had a minimum composition of five patient profiles. Comparisons of GVHS cost weights to CIHI RIWs yielded mostly positive results. With the noted exception of about 20 CMGs, there was a high correlation between the CIHI RIW and the GVHS actual cost weights. Hence, the GVHS cost weights can be viewed with confidence as representative of the relative cost differences between typical RIW value CMGs and actual costs.
Article
Background: One-year follow-up data from the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial show that use of low-molecular-weight heparin (enoxaparin) compared with unfractionated heparin in patients hospitalized with unstable angina or non-Q-wave myocardial infarction is associated with a 10% reduction in the cumulative 1-year risk of death, myocardial infarction, or recurrent angina. Given the higher acquisition cost of enoxaparin relative to unfractionated heparin, we assessed whether the reduced use of revascularization procedures and related care makes enoxaparin a cost-saving therapy in Canada. Methods and results: We analyzed cumulative 1-year resource use data on the 1259 ESSENCE patients enrolled in Canadian centers (40% of the total ESSENCE sample). Patient-specific data on use of drugs, diagnostic cardiac catheterization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, and hospital days were available from the initial hospital stay and cumulative to 1 year. Hospital resources were costed with the use of data from a teaching hospital in southern Ontario that is a participant in the Ontario Case Costing Project. During the initial hospital stay, use of enoxaparin was associated with reduced use of diagnostic catheterization and revascularization procedures, with the largest effect being reduced use of percutaneous transluminal coronary angioplasty (15.0% vs 10.6%; P =.03). At 1 year, the reduced risk and costs of revascularization more than offset increased drug costs for enoxaparin, producing a cost-saving per patient of 1485(951485 (95% confidence interval -93 to 3167;P=.06).SensitivityanalysiswithlowerhospitalperdiemcostsfromacommunityhospitalinOntariostillpredictscostsavingsof3167; P =.06). Sensitivity analysis with lower hospital per diem costs from a community hospital in Ontario still predicts cost savings of 1075 per patient over a period of 1 year. Conclusions: The acquisition and administration cost of enoxaparin is higher than for unfractionated heparin (101vs101 vs 39), but in patients with acute coronary syndrome, the reduced need for hospitalization and revascularization over a period of 1 year more than offsets this initial difference in cost. Evidence from this Canadian substudy of ESSENCE supports the view that enoxaparin is less costly and more effective than unfractionated heparin in this indication.
Article
There is growing evidence that homeless individuals have longer inpatient lengths of stay with significantly higher medical costs than domiciled individuals. We compared adjusted mean lengths of stay among domiciled patients and homeless patients discharged to a hospital hotel (hoptel). Because the hoptel allowed homeless patients to be discharged when medically indicated, we hypothesized no significant differences in lengths of stay between the 2 groups after adjustment for severity of illness. Demographic, diagnosis, and length of stay data were obtained for all patients discharged from all inpatient wards at a large, urban Veterans Affairs Medical Center during the first 32 months of hoptel operation (1996 through 1998). Adjusted mean lengths of stay for domiciled patients and homeless patients discharged to the hoptel were compared. ANCOVA was used to adjust for demographic characteristics (age, income, race/ethnicity), diagnosis-related group (DRG), principal diagnosis, and substance abuse comorbidity. Three types of hospitalizations were analyzed on the basis of major DRG categories: general medical, psychiatric, and all hospitalizations. No significant differences were found in adjusted mean lengths of stay between domiciled patients and homeless patients discharged to the hoptel. Homeless hoptel patients stayed an average 0.7, 0.3, and 0.4 days longer than domiciled patients for all, general medical, and psychiatric hospitalizations (P = 0.504, 0.627, and 0.839), respectively. These data suggest that hoptels may help equalize inpatient lengths of stay among domiciled and homeless patients discharged to a hoptel. Public health care systems seeking innovative ways of reducing inpatient lengths of stay among homeless patients ought to consider establishing hoptels.
Article
Economic evaluation is often seen as a branch of health economics divorced from mainstream econometric techniques. Instead, it is perceived as relying on statistical methods for clinical trials. Furthermore, the statistic of interest in cost-effectiveness analysis, the incremental cost-effectiveness ratio is not amenable to regression-based methods, hence the traditional reliance on comparing aggregate measures across the arms of a clinical trial. In this paper, we explore the potential for health economists undertaking cost-effectiveness analysis to exploit the plethora of established econometric techniques through the use of the net-benefit framework - a recently suggested reformulation of the cost-effectiveness problem that avoids the reliance on cost-effectiveness ratios and their associated statistical problems. This allows the formulation of the cost-effectiveness problem within a standard regression type framework. We provide an example with empirical data to illustrate how a regression type framework can enhance the net-benefit method. We go on to suggest that practical advantages of the net-benefit regression approach include being able to use established econometric techniques, adjust for imperfect randomisation, and identify important subgroups in order to estimate the marginal cost-effectiveness of an intervention.
Article
Homeless individuals experience high rates of physical and mental illness, increased mortality, and frequent hospitalizations. Respite care provides homeless individuals with housing and services allowing more complete recovery from illnesses and stabilization of chronic conditions. We investigated respite care's impact on 225 hospitalized homeless adults consecutively referred from an urban public hospital during a 26-month period. The cohort was separated into 2 groups: (1) patients referred and accepted into the respite center and (2) patients referred but denied admission because beds were unavailable. All patients met the center's predefined eligibility criteria. Main outcome measures were inpatient days, emergency department visits, and outpatient clinic visits. The 2 groups had similar demographic characteristics, admitting diagnoses, and patterns of medical care use at baseline. During 12 months of follow-up, the respite care group required fewer hospital days than the usual care group (3.7 vs 8.3 days; P=.002), with no differences in emergency department or outpatient clinic visits. Individuals with HIV/AIDS experienced the greatest reduction in hospital days. Respite care after hospital discharge reduces homeless patients' future hospitalizations.
Article
Little is known about the health status of those who are newly homeless. We sought to describe the health status and health care use of new clients of homeless shelters and observe changes in these health indicators over the study period. We conducted a longitudinal study of 445 individuals from their entry into the homeless shelter system through the subsequent 18 months. Disease was prevalent in the newly homeless. This population accessed health care services at high rates in the year before becoming homeless. Significant improvements in health status were seen over the study period as well as a significant increase in the number who were insured. Newly homeless persons struggle under the combined burdens of residential instability and significant levels of physical disease and mental illness, but many experience some improvements in their health status and access to care during their time in the homeless shelter system.
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