Article

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

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

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) and 3081 homeless patient admissions (mean cost, $13,516). After adjustment for age, gender, and resource intensity weight, homeless patient admissions cost $2559 more than housed patient admissions (95% CI, $2053, $3066). 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.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... H omeless individuals experience a higher rate of emergency depart ment visits, increased lengths of hospital stay, and increased healthcare costs rel ative to the general population. 1,2 It has been shown that homeless patients cost the healthcare system $2,559 (Canadian dollars) more per hospital admission than housed patients. 2 Medication non adherence is one factor that has been linked to poor health outcomes. ...
... 1,2 It has been shown that homeless patients cost the healthcare system $2,559 (Canadian dollars) more per hospital admission than housed patients. 2 Medication non adherence is one factor that has been linked to poor health outcomes. [3][4][5] Known barriers to medication adherence among the homeless population include medi cation cost, lack of access to a physician, and uncontrolled mental illness. ...
... Our institution accounts for approximately 25% of admissions of homeless patients in Toronto, Ontario, Canada. 2 The frequent admission of homeless patients to our institution provided an opportunity to study perceptions toward medication taking. The objective of the study described here was to characterize the perceptions, attitudes, and beliefs about prescribed medications held by hospitalized pa tients who are homeless. ...
Article
Purpose Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. Methods A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients’ views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients’ admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. Results Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. Conclusion In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.
... Not only are IEH hospitalized more often than housed individuals, they also have longer lengths of stay (LOS) in hospital, which presents an additional burden on both the individual and on society. In general, IEH spend between 2.3 and 4.1 more days in hospital [11] [12] [13] than housed individuals, however this data is aggregate data not identifying which disease types most contribute to this LOS. Hwang et al. noted that in Canada, even after adjustment for age, gender, and resource intensity weight, hospitalizations for IEH cost over $2500 more than for housed individuals [12]. ...
... In general, IEH spend between 2.3 and 4.1 more days in hospital [11] [12] [13] than housed individuals, however this data is aggregate data not identifying which disease types most contribute to this LOS. Hwang et al. noted that in Canada, even after adjustment for age, gender, and resource intensity weight, hospitalizations for IEH cost over $2500 more than for housed individuals [12]. Concomitant mental health concerns are common in IEH and impact both rates of hospital admissions, LOS, and hospitalization costs [14], with admissions to psychiatry costing over $1000 more for IEH (even while adjusting for length of stay) [12]. ...
... Hwang et al. noted that in Canada, even after adjustment for age, gender, and resource intensity weight, hospitalizations for IEH cost over $2500 more than for housed individuals [12]. Concomitant mental health concerns are common in IEH and impact both rates of hospital admissions, LOS, and hospitalization costs [14], with admissions to psychiatry costing over $1000 more for IEH (even while adjusting for length of stay) [12]. ...
Preprint
Full-text available
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 utilization. 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. 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 admissions were associated with increased LOS regardless of gender or age group. The absolute mean difference of LOS between IEH and housed individuals was 1.62 hours [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 numerous diagnoses that are associated with increased LOS in IE; these inform the prioritization and development of targeted interventions to improve the health of IEH.
... Housing status affects access to preventive or primary healthcare, and therefore, people experiencing homelessness use the acute healthcare system at higher rates than the general population (Hwang et al. 2013). Healthcare needs for people experiencing homelessness may be more advanced and complex than for their housed, low-income peers, resulting in longer average in-patient stays (Hwang et al. 2011). Longer in-patient stays may also be associated with difficult discharges (e.g., difficulty finding a discharge destination to meet the patient' s complex needs). ...
... These admissions have financial impacts for the healthcare system. Longer hospital stays for homeless patients are associated with increased costs for treating these patients (in Toronto, $961 more per admission for homeless than housed patients, or $2,559 more when adjusting for age, gender and resource intensity; Hwang et al. 2011). People experiencing homelessness are less able to access care at early stages of illness, resulting in more severe and complex symptoms by the time they present at hospitals, as well as correspondingly higher rates of hospital admission. ...
... Jenkinson et al. (2020) concisely summarize key points from the large body of literature that links homelessness to poor health outcomes and to higher hospital need. People who are homeless tend to have multiple mental and physical illnesses, and they remain in the hospital longer and are more likely to visit the emergency department and/or be readmitted after discharge (Hwang et al. 2011;Mikkonen and Raphael 2010;Munn-Rivard 2014). Managing one' s health while homeless is not easy. ...
Article
There are complex issues surrounding hospital discharge planning for people experiencing homelessness. The issue involves the disconnection across policy areas of housing, income supports and mental health, and later health generally. Different models for different types of communities (large urban, mid-size, small and rural areas) likely need to be developed as well as for different types of conditions and different housing histories. The quality of data needs improvement including accuracy. Housing items need to be part of admission processes so that the need for post-discharge housing can be quickly flagged and more accurate data can be made available. System improvements need to include all levels of government, people with lived experience, and health as well as housing/homeless sectors. The income support sector also needs to be included. Discharge planning often assumes there is a fixed address after discharge. This clearly misses the needs of people who have lost their housing.
... Risk factors for ALC include neuro-cognitive impairment, such as stroke, dementia, psychiatric illness or delirium [1,2,8,9], social support needs, informal caregiver needs [10], lack of spouse and/or children [9] and homelessness [11]. The majority of ALC patients begin their hospitalization through the emergency department [2]. ...
... Strategies to reduce ALC days include initiatives to prevent hospitalization, including community falls prevention programs, emergency department geriatric screening for ALC risk [8,12,14], discharge capability with community supports, provision of hospital care in long term care facilities [15], community dementia screening and early management [1] and "assertive outreach through community mental health programs" for the homeless [11]. If hospitalized, these individuals require multidisciplinary interventions for functional decline prevention [12] and promotion of early discharge to home with supports [12], restorative or transitional care units [16,17] ...
... Costs were derived through case costing, an accepted method for determining actual hospital costs in Ontario [10,11] [21]. Direct costs are those directly associated with patient care such as nursing, allied health, diagnostic therapeutic services, pharmaceutical and medical surgical supplies. ...
Preprint
Full-text available
Background: Alternate level of care (ALC) patients are those who reside in acute hospital beds but can be managed in non-hospital settings. They contribute to high occupancy levels in Canadian hospitals. Between 2017-18, Ontario spent 1.1 billion dollars on hospitalized patients waiting for alternate level of care (ALC) beds. To improve value for care, Ontario Ministry of Health (MOHLTC) invested into reintegration units which are designed to transfer ALC patients out of hospital and transition them back into the community or long-term care (LTC). Given today’s healthcare budget pressures, it is unclear if reactivation units are feasible. In 2018, the MOHLTC funded a reintegration unit, Pine Villa with an operational partner, Sunnybrook Hospital and community service providers (SPRINT Senior Care, LOFT) in Toronto, Ontario. The objective was to determine averted costs for ALC-patients and impact on Sunnybrook patient flow-through if ALC-patient Pine Villa transfers occurred on the day of ALC readiness. Methods: Retrospective, observational analysis of Sunnybrook ALC-patients discharged to Pine Villa between January 9, 2018 to February 4, 2019. From the healthcare payer’s perspective (MOHTLC), cost analysis was modelled for ALC patients designated for 1) LTC and 2) home with supports. Avoided costs at time of ALC readiness were determined by case-costing. Averted hospital ALC days were established. Results: If ALC patients were transferred to Pine Villa at time of ALC readiness for LTC, the healthcare system could have averted 5.4 million dollars from Sunnybrook. If the patients were transferred for home, 2.3 million dollars could have been averted. Both models increased acute Sunnybrook Hospital capacity by 34 beds. Conclusion: There is a business case supporting reintegration units if ALC-patients are discharged from the hospital on the day of ALC-readiness.
... 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
Full-text available
Hospital discharge is a key transition in a patient's care pathway, providing an effective point of intervention to address a patient's ongoing health and social care needs. Addressing these needs may prevent hospital readmissions. The hospital discharge process for people experiencing homelessness who have been admitted for medical conditions has not been well-characterized. To address this gap in knowledge, we interviewed hospital and shelter workers, and key informants, about their experiences when unhoused patients are discharged from hospitals to shelters. Using critical realism, we explored the organizational and service context of this process by looking at the relationship between structures and agency in the daily work of our participants. Our results indicate that the discharge process for unhoused patients was shaped by two systems failures, barriers to publicly funded systems including community resources, and silos and gaps between these systems, ultimately leading to failed transitions to the community. The most prominent manifestations of these systems failures were a) limited and inadequate access to post-discharge care and services, b) barriers to accessing shelters, c) inadequate service integration between healthcare and social service sectors, and, d) poor cross-sectoral knowledge between hospital and shelter workers. We characterize the discharge process for unhoused patients as a part of a larger systems failure in the care for unhoused patients and contend that improvements in hospital discharges requires changes to underlying structures that lead to inadequate discharges.
... The discharge process for people experiencing homelessness is not well characterized in the Canadian context. Research primarily examines hospital length of stay and discharge outcomes such as hospital readmission (Hwang et al., 2011;Hwang et al., 2013;Saab et al., 2016), or discharge from long-term and acute mental healthcare (Forchuk et al., 2013). Less research focuses on discharge after hospitalization for physical health conditions, despite frequent admissions and long lengths of stay for homeless patients admitted to medical and surgical services (Hwang et al., 2011). ...
... Research primarily examines hospital length of stay and discharge outcomes such as hospital readmission (Hwang et al., 2011;Hwang et al., 2013;Saab et al., 2016), or discharge from long-term and acute mental healthcare (Forchuk et al., 2013). Less research focuses on discharge after hospitalization for physical health conditions, despite frequent admissions and long lengths of stay for homeless patients admitted to medical and surgical services (Hwang et al., 2011). A small number of studies have described barriers or challenges to discharging homeless patients from acute care (e.g., Buccieri et al., 2018), but are not explicit on why and how these challenges exist. ...
Article
Objectives A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. Methods Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. Results Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. Conclusion Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.
... [9][10][11][12] Together, these factors contribute to high rates of hospital service use and costs. [13][14][15] Given increasing rates of homelessness and the impact of homelessness on health, 16 there is an urgent need for interventions to improve health outcomes in this population, including avoidable hospital service utilization. 14 For adults experiencing mental illness, care following discharge from hospital for a mental health condition is reportedly the most important factor in reducing reliance on subsequent inpatient care. ...
... [13][14][15] Given increasing rates of homelessness and the impact of homelessness on health, 16 there is an urgent need for interventions to improve health outcomes in this population, including avoidable hospital service utilization. 14 For adults experiencing mental illness, care following discharge from hospital for a mental health condition is reportedly the most important factor in reducing reliance on subsequent inpatient care. 17 Adults experiencing mental illness and homelessness, however, are less likely to be referred to and access community-based services upon discharge from hospital, compared to housed individuals. ...
Article
Objective This study evaluated the impact of a critical time intervention (CTI) adaptation on health care utilization outcomes among adults experiencing homelessness and mental health needs in a large urban center. Methods Provincial population-based administrative data from Ontario, Canada, were used in a pre–post design for a cohort of 197 individuals who received the intervention between January 2013 and May 2014 and were matched to a cohort of adults experiencing homelessness who did not receive the intervention over the same time period. Changes in health care utilization outcomes in the year pre- and postintervention were evaluated using generalized estimating equations, and post hoc analyses evaluated differences between groups. Results Pre–post analyses revealed statistically significant changes in health care utilization patterns among intervention recipients, including reduced inpatient service use and increased outpatient service use in the year following the intervention compared to the year prior. However, the matched cohort analysis found nonsignificant differences in health service use changes between a subgroup of intervention recipients and their matched counterparts. Conclusions An adapted CTI model was associated with changes in health care utilization among people experiencing homelessness and mental health needs. However, changes were not different from those observed in a matched cohort. Rigorous study designs with adequate samples are needed to examine the effectiveness of CTI and local adaptations in diverse health care contexts.
... Housing status affects access to preventive or primary healthcare, and therefore, people experiencing homelessness use the acute healthcare system at higher rates than the general population (Hwang et al. 2013). Healthcare needs for people experiencing homelessness may be more advanced and complex than for their housed, low-income peers, resulting in longer average in-patient stays (Hwang et al. 2011). Longer in-patient stays may also be associated with difficult discharges (e.g., difficulty finding a discharge destination to meet the patient' s complex needs). ...
... These admissions have financial impacts for the healthcare system. Longer hospital stays for homeless patients are associated with increased costs for treating these patients (in Toronto, $961 more per admission for homeless than housed patients, or $2,559 more when adjusting for age, gender and resource intensity; Hwang et al. 2011). People experiencing homelessness are less able to access care at early stages of illness, resulting in more severe and complex symptoms by the time they present at hospitals, as well as correspondingly higher rates of hospital admission. ...
Article
People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.
... Badger uses the term "costly affordable housing." Several researchers have proposed that building affordable housing and supports for those who are poor is more humane and economically beneficial (National Council of Welfare, 2011; Gaetz, 2012;Latimer et al., 2017;Palermo, Dera, & Clyne 2006;Hwang et al., 2011;Patterson et al., 2008). When we can see benefits in the future, then costs should actually be considered as investments (National Council of Welfare, 2011). ...
... For Toronto specifically, another study wanted to determine if housed patients cost more or less per hospital admission than those who are homeless over a 5-year period in Toronto. They found that "…homeless patient admissions cost $2559 more than housed patient admissions" and patients using psychiatric services "…cost $1058 more than housed patient admissions" (Hwang et al., 2011). From a Wellesley Institute study, we know that taxpayers pay "two and one-half times as much for homeless shelters as for rent supplements. ...
Thesis
Full-text available
Discourses about people who are rich and those who are poor are pervasive in our society. Online news media is one of the ways in which these power dominated messages are disseminated. Forty online news articles from four major news outlets in Canada were examined using Critical Discourse Analysis. Questions about how the language used in these news articles perpetuates stigma for people who are poor were explored. The findings show that most news articles use some form of stigmatizing language that has a detrimental impact on how people living in poverty are perceived. Negative stereotypes were pervasive, especially in the more conservative leaning news organizations. Ways of changing this language, and methods for reducing stigma are investigated.
... Homeless people generally have higher mortality and morbidity, including a high prevalence of psychiatric disorders and substance use problems [1,4,5]. Overall, this leads to substantially higher use of health care services and more frequent hospitalizations, resulting in higher health care costs compared to the general population [6][7][8]. Over the last decade, the average number of inpatient days has decreased, and there has been a tendency to provide more health care on an outpatient basis [9]. ...
... Doran et al. showed that 70.3% of all hospitalizations of homeless people result in either readmission or an emergency department visit within 30 days after discharge, with approximately 75% of the hospital readmissions occurring within the first 2 weeks after hospital discharge [11]. Another consequence of homelessness is prolongation of in-hospital stay due to postponement of discharge [8], also termed "alternative level of care", referring to patients who no longer need the treatment provided in acute care hospitals [12]. ...
Article
Full-text available
Background: Being homeless entails higher mortality, morbidity, and prevalence of psychiatric diseases. This leads to more frequent and expensive use of health care services. Medical respite care enables an opportunity to recuperate after a hospitalization and has shown a positive effect on readmissions, but little is known about the cost-effectiveness of medical respite care for homeless people discharged from acute hospitalization. Therefore, the aim of the present study was to investigate the cost-effectiveness of a 2-week stay in post-hospital medical respite care. Methods: A randomized controlled trial and cost-utility analysis, from a societal perspective, was conducted between April 2014 and March 2016. Homeless people aged > 18 years with an acute admission were included from 10 different hospitals in the Capital Region of Denmark. The intervention group (n = 53) was offered a 2-week medical respite care stay at a Red Cross facility and the control group (n = 43) was discharged without any extra help (usual care), but with the opportunity to seek help in shelters and from street nurses and doctors in the municipalities. The primary outcome was the difference in health care costs 3 months following inclusion in the study. Secondary outcomes were change in health-related quality of life and health care costs 6 months following inclusion in the study. Data were collected through Danish registries, financial management systems in the municipalities and at the Red Cross, and by using the EQ-5D questionnaire. Results: After 3 and 6 months, the intervention group had €4761 (p = 0.10) and €8515 (p = 0.04) lower costs than the control group, respectively. Crude costs at 3 months were €8448 and €13,553 for the intervention and control group respectively. The higher costs in the control group were mainly related to acute admissions. Both groups had minor quality-adjusted life year gains. Conclusions: This is the first randomized controlled trial to investigate the cost-effectiveness of a 2-week medical respite care stay for homeless people after hospitalization. The study showed that the intervention is cost-effective. Furthermore, this study illustrates that it is possible to perform research with satisfying follow-up with a target group that is hard to reach. Trial registration: ClinicalTrials.gov Identifier: NCT02649595.
... There is disproportionate use of acute health services by those experiencing homelessness [9]. People experiencing homelessness more frequently re-present to the emergency department (ED) and have longer lengths of stay once admitted [10,11] compared to the general population. This review examines the characteristics included in existing vulnerability indices, how they have been applied and any direct health outcomes achieved by applying them. ...
... In the context of homelessness, the first vulnerability index was developed in 2007 by Common Ground, a homelessness service in New York City, for the purpose of assessing medical vulnerability and to prioritise housing for people experiencing homelessness [12]. Based on the findings of earlier research [10], this original vulnerability index provides a framework to prioritise housing need by identifying the most medically vulnerable people experiencing homelessness through a standardised assessment, which quantifies the individual's risk for mortality. It comprises nine criteria, including length of homelessness (days, months, years), number of hospital admissions and emergency department admissions in a year, age, cirrhosis of the liver, end stage renal disease, history of frost-bite/hypothermia, HIV+/AIDS, mental health, substance use and chronic health conditions. ...
Article
Full-text available
Background: The objectives of this scoping review are to investigate the characteristics assessed by existing vulnerability indices and the health outcomes achieved by applying them to people experiencing homelessness. This review forms part of the development and implementation of a novel tool to prioritise people experiencing homelessness for healthcare based on their need and capacity to access healthcare. Methods: Included papers were primary research, published in the English language, participants were experiencing homelessness and aged over 18 years at the time of the study, a vulnerability index was used in the study, sample size was greater than 30, and the study had a health focus. Databases searched were MEDLINE, Embase, CINAHL, Scopus, PubMed and Web of Science, between January-April 2020. The Joanna Briggs Appraisal criteria were used to quality appraise the included studies. Results were synthesised narratively. Results: Six papers were included, a total of 27,509 participants. The reported use of the indices varied; they included screening and profiling homeless populations, comparing homeless populations, and two studies evaluated the predictive capacity, reliability and validity of the indices. One vulnerability index focused on screening for human immunodeficiency virus, one used a 50-item index and four used a nine-item index. No direct health outcomes were reported from applying the vulnerability indices. The studies identified limitations of using vulnerability indices, including the potential bias of relying on self-reported data and two studies highlighted the need for further psychometric testing to ensure validity and reliability of the indices. Discussion: The sample of included studies was small. Vulnerability indices are reportedly a useful and easily accessible method of gaining valuable data on the health status and health needs of people experiencing homelessness. The variety of characteristics included in the vulnerability indices suggests the importance of tailoring vulnerability indices to the needs of the population to which it is to be applied. Conducting appropriate psychometric testing is critical so that an index can be used to accurately inform decision making and accurately prioritise people experiencing homelessness who are most at risk of mortality and morbidity. A specific tool that prioritises people experiencing homelessness for access to health care is not yet available. The review was funded by a St Vincent's Network Inclusive Health grant.
... Even in countries that have universal health care such as Canada, hospitalized individuals who experience homelessness cost $2,559 more than those who do not. 11 A 2017 study showed "medical system charges for these participants decreased by 48.6% from the year prior to the year following medical respite." 12 ...
... Emergency Department overutilization creates strain on the healthcare system and can lead to ineffective care for these patients. Homeless patients have an average of 2.32 days longer length of stay, and approximately $1000 increased hospital costs per discharge [20]. Researchers have called for the development of ED-based interventions that specifically address homeless patients' needs, reduce mortality, improve cost-effectiveness, and relieve overcrowding [15,21]. ...
Article
Full-text available
Background Annually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care. Methods A needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted. Results Twenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders. Conclusion CBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.
... High rates of revisits among the homeless population following a hospitalization-which include hospital readmission or a return to the ED without requiring an admission-are quite costly to the U.S. health care system, and they may reflect suboptimal quality of care delivered to these patients or other unmet needs. 11,12 Recognizing the importance of preventing revisit rates to hospitals, federal and state governments have introduced programs and policies to enhance care coordination and discharge planning through mandatory national hospital penalty programs, including the Hospital Readmissions Reduction Program (HRRP). 13 Some states implemented policies to directly target the revisits of the homeless population. ...
Article
Full-text available
Background As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable.Objective To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients (“homeless-serving” hospitals—defined as hospitals in the top decile of the proportion of homeless patients).DesignA population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.ParticipantsParticipants were 3,527,383 patients (median age [IQR]: 63 [49–77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals.Main MeasuresRisk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.Key ResultsAfter adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69–2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74–2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.Conclusions Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.
... increase in all-cause mortality. [6][7][8] Health care expenditures associated with treating those experiencing homelessness are 3.8-fold higher than housed persons, 7,9 and people experiencing homelessness are more likely to be high-utilizers of the emergency department (ED). 2,3,[10][11][12][13][14] In Maine, the number of people experiencing homelessness grew 37% from 2010 to 2019. ...
... Homelessness has been suggested to be at the most extreme end of the scale of health inequality in high-income societies (7). Furthermore, the high economic costs associated with homeless people (8,9) support the arguments for improving the efforts of reducing problems with homelessness. However, the number of homeless people is increasing in most of these countries (1,(10)(11)(12). ...
Article
Objective: To examine the absolute and relative risk of homelessness following discharge from psychiatric wards in Denmark. Methods: A nationwide, register-based, cohort study including people aged 18+ years discharged from psychiatric wards in Denmark between Jan 1, 2001 and Dec 31, 2015. We analysed associations between psychiatric diagnoses and risk of homelessness using survival analysis. Results: 126,848 psychiatric inpatients were included accounting for 94,835 person-years. The incidence of homelessness one year following discharge was 28.18 (95% CI 26.69-29.75) and 9.27 (95% CI 8.45-10.16) per 1000 person-years at risk in men and women, respectively. The one-year cumulative probability of first homelessness after discharge from psychiatric wards was 1.58% (95% CI 1.48-1.68) in males and 0.55% (95% CI 0.50-0.61) in females. Substance use disorders increased the risk of homelessness after discharge with adjusted incidence rate ratios of 6.60 (95% CI 5.19-8.40) (men) and 13.06 (95% CI 9.31-18.33) (women), compared with depressive disorders. Prior history of homelessness was an important predictor for homelessness following discharge. Conclusions: The first year following discharge from psychiatric wards is a high-risk period of homelessness, especially when having a substance use disorder or a prior history of homeless shelter contact. Improved efforts to prevent homelessness are needed. This article is protected by copyright. All rights reserved.
... People experiencing homelessness and mental illness have significantly poorer mental and physical health and quality of life relative to the general population (1)(2)(3). In addition, compared to the general population, they have higher rates of acute care utilization and associated costs (2,4,5). Efforts to improve the health and health service use outcomes of this population have historically been challenged by poor service engagement and high drop-out rates (6). ...
Article
Full-text available
Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods ( ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.
... Any period of homelessness has been shown to be an indicator of a greater risk of severe mental disorders, such as schizophrenia or bipolar disorder, alcohol and drug dependence, and physical health problems, including a shorter lifespan than that of the general population (Fazel et al., 2014;Nordentoft, 2003). This population faces barriers to accessing primary healthcare, leading to high utilization of healthcare (emergency departments or hospitals) and justice and social services (Fazel et al., 2014;Hwang et al., 2011;Kovess and Mangin Lazarus, 1999;Latimer et al., 2017;Schmoll et al., 2015). ...
... Homelessness and lack of access to stable housing represent a major public health crisis, resulting in poor health outcomes and high treatment costs [1][2][3]. The US Department of Veterans Affairs (VA) administers several nationwide programs for addressing homelessness among Veterans. ...
Article
Full-text available
Housing stability is an important determinant of health. The US Department of Veterans Affairs (VA) administers several programs to assist Veterans experiencing unstable housing. Measuring long-term housing stability of Veterans who receive assistance from VA is difficult due to a lack of standardized structured documentation in the Electronic Health Record (EHR). However, the text of clinical notes often contains detailed information about Veterans’ housing situations that may be extracted using natural language processing (NLP). We present a novel NLP-based measurement of Veteran housing stability: Relative Housing Stability in Electronic Documentation (ReHouSED). We first develop and evaluate a system for classifying documents containing information about Veterans’ housing situations. Next, we aggregate information from multiple documents to derive a patient-level measurement of housing stability. Finally, we demonstrate this method’s ability to differentiate between Veterans who are stably and unstably housed. Thus, ReHouSED provides an important methodological framework for the study of long-term housing stability among Veterans receiving housing assistance.
... People experiencing homelessness face numerous obstacles to accessing appropriate healthcare and frequently present at hospital with advanced disease conditions and potentially lifethreatening illness [1]. Given their lack of a secure, stable place to live, deficiencies in the quality of care and disproportionate exposure to substance and frequent alcohol consumption, homeless people may exhibit increased rates of prior acute health service use, including emergency department, hospital admissions [2,3] unplanned readmissions [4], prolonged hospital lengths of stay (LOS) and more costly care than those who are domiciled [5][6][7][8]. ...
Article
Background No research was conducted on the clinical characteristics and outcomes of Infectious Disease Units (IDU) managed homeless patients (HP). Methods We conducted retrospectively a survey among 98 HP and 98 non-HP admitted between 2017 and 2018 in several IDUs in Marseille, France. Results HP were more likely to be migrant, to report frequent alcohol consumption or illicit drug use, and to present with respiratory symptoms at admission compared to controls. The most common final diagnoses in HP were respiratory tract infections (other than pulmonary tuberculosis [PTB], 35.7%), sexually transmitted infections (20.4%), cutaneous and mucosal infections (19.4%) and tuberculosis (12.2%). Sexually transmitted infections and ectoparasite infestations were significantly more frequent in HP compared to controls. One HP died from pleural effusion as a complication of PTB. The surviving HP had a longer length of stay (LOS, average 11.6 ± 13.6 days, p < 0.0001) than controls; independent factors of increased LOS were tobacco use (p = 0.009), tuberculosis infection (p < 0.0001), urinary tract infection (p = 0.018) and bacteraemia (p = 0.018). After hospital discharge, attendance at subsequent planned consultations was significantly lower in HP (0.72 ± 1.25 times/persons) compared to controls (2.03 ± 2.2). Conclusions We suggest that HP present specific demographic characteristics and patterns of infectious diseases compared to other patients and require adapted management.
... Among the homeless and vulnerably housed, the probability of survival to age 75 is 32% for men and 60% for women (6). Patients who are homeless remain hospitalized longer, resulting in higher costs, especially when there is concomitant mental illness and addictions (7)(8)(9)(10)(11). Homelessness and poverty are significant barriers to care; often forcing individuals to prioritize food and basic needs over adherence to recommended medical care (10,12,13). ...
Article
Full-text available
Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome , to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.
... It has been demonstrated that homeless people are particularly exposed to several medical conditions, such as heart and vascular diseases, diabetes, hypertension, chronic obstructive pulmonary disease, and infections, often presenting with acute onsets and requiring long hospital stays. [36][37][38][39][40] In our sample, we found a range of comorbidities among homeless persons, with the most common being active cardiovascular conditions, psychiatric conditions, osteoarticular diseases, and dermatologic issues; furthermore, .50% of our patients presented at least 1 comorbidity. In this vulnerable population, the need for health care often comes after the need for food and shelter, thus leading to important diagnostic delays and increases in morbidity and mortality. ...
Article
Objective Otolaryngology diseases are common among people experiencing homelessness; however, they are seldom evaluated in a specialist setting, and investigations on their prevalence have rarely been conducted. The aim of this retrospective study was to evaluate the prevalence of otolaryngology conditions in an urban homeless population. Study Design Retrospective study. Setting Primary health care facility. Methods The clinical records of patients referred to the medical facilities of the Primary Care Services of the Eleemosynaria Apostolica, Vatican City, between October 1, 2019, and July 31, 2021, were retrospectively reviewed; those reporting at least 1 otolaryngology disease were included in the study. Results A total of 2516 records were retrospectively reviewed, and 484 (19.24%) were included in the study. The most common otolaryngology disease was pharyngotonsillitis (n = 118, 24.13%), followed by rhinitis with nasal obstruction (n = 107, 21.88%), hearing loss (n = 93, 19.01%), otitis (n = 81, 16.56%), abscess (n = 46, 9.40%), and sinusitis (n = 33, 6.74%). Head and neck cancer or precancerous lesions were reported in 34 subjects (7.02%). More than 1 simultaneous otolaryngology disorder was found in nearly 50% of our sample. A wide range of comorbidities was also reported. Conclusions Our results confirm an elevated otolaryngology demand in the homeless population and encourage the development of more efficient and effective strategies for a population-tailored diagnosis and treatment of these conditions.
... For example, some people experiencing homelessness report that they delay treatment-seeking because they do not want to waste the time of doctors who could be treating other people who are sicker (21). Such a view may lead to a deterioration in health and a more severe presentation when people ultimately do seek care-a common occurrence with the homeless population (30). A second personal belief that can affect service experiences is feeling the need to hide parts of one's life to receive treatment. ...
Chapter
People experiencing homelessness use a range of health, social, and community services to meet their various unmet needs. However, this population also commonly reports negative experiences using services, which can lead to service discontinuation, exacerbation of health problems, and further entrenchment in homelessness. This chapter reviews the research on the factors that contribute to positive and negative service experiences among people who are homeless. Seven categories of factors are identified: [1] accessibility, [2] personal beliefs, [3] organizational policies and procedures, [4] interactions with service providers, [5] sense of safety and welfare, [6] service environment and quality, and [7] outcomes and follow-up. Overall, the evidence suggests that service use for people experiencing homelessness can be a series of challenges and frustrations rather than a straightforward means to better health and housing.
... 15 Homelessness is associated with significantly higher emergency department use 16,17 and hospital inpatient use compared with the general population that leads to substantial excess healthcare costs. 18,19 Taken together, this suggests that additional safety nets and services are needed to support the healthcare needs of the homeless population. Given the high rates of homelessness in California, the need for ophthalmic care in the homeless population and its association with high healthcare costs, we addressed the need for a free eye clinic in San Francisco at a homeless shelter. ...
... The literature on healthcare system use among homeless people is small and mainly from North America and the UK. [24][25][26] These studies predominantly show low utilisation of primary care and an almost exclusive use of emergency care or hospital-based care due to more severe and complex health conditions. 27 Recent studies from Canada suggest that heavy use of emergency care is mainly associated with a small group of 'high users' among homeless people. ...
Article
Full-text available
Objective To determine the housing situation among people seeking psychiatric treatment in relation to morbidity and service utilisation. Design Cross-sectional patient survey. Setting Psychiatric centre with a defined catchment area in Berlin, Germany, March–September 2016. Participants 540 psychiatric inpatients including day clinics (43.2% of all admitted patients in the study period (n=1251)). Main outcome measures Housing status 30 days prior the interview as well as influencing variables including service use, psychiatric morbidity and sociodemographic variables. Results In our survey, 327 participants (68.7%) currently rented or owned an own apartment; 62 (13.0%) reported to be homeless (living on the street or in shelters for homeless or refugees); 87 (18.3%) were accommodated in sociotherapeutic facilities. Participants without an own apartment were more likely to be male and younger and to have a lower level of education. Homeless participants were diagnosed with a substance use disorder significantly more often (74.2%). Psychotic disorders were the highest among homeless participants (29.0%). Concerning service use, we did neither find a lower utilisation of ambulatory services nor a higher utilisation of hospital-based care among homeless participants. Conclusions Our findings underline the need for effective housing for people with mental illness. Despite many sociotherapeutic facilities, a concerning number of people with mental illness is living in homelessness. Especially early interventions addressing substance use might prevent future homelessness.
... 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
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 ($4752 vs $2520 for females) and for cases with higher comorbidity ($1394-$7751) (both P < .001) but were similar across levels of most marginalization dimensions (range $3232-$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.
Article
The United States is facing a growing homelessness crisis. We characterize the demographics and outcomes of homeless patients who sustain burn injury and compare them to a cohort of domiciled patients. A retrospective cohort study was performed at the Los Angeles County + University of Southern California Regional Burn Center for consecutive acute burn admissions in adults from June 1, 2015, to December 31, 2018. Patients were categorized as either domiciled or homeless at the time of their injury. Prevalence rates were estimated using data from the regional homeless count. From 881 admissions, 751 (85%) had stable housing and 130 (15%) were homeless. The rate of burn injury requiring hospitalization for homeless adults was estimated at 88 per 100,000 persons. Homeless patients had a significantly larger median burn size (7 vs 5%, P < .05) and a greater rate of flame burns (68 vs 42%, P < .001). For the homeless, rates of assault and self-inflicted injury were 4- (18 vs 4%, P < .001) and 2-fold higher (9 vs 4%, P < .001), respectively. Homeless patients had higher rates of mental illness (32 vs 12%, P < .001) and substance abuse (88 vs 22%, P < .001), and were less likely to follow-up as outpatients (54 vs 87%, P < .001). There was no difference in mortality. Homeless patients had a longer median length of stay (LOS; 11 vs 7 days, P < .001) without significant differences in LOS per percentage TBSA. Homeless individuals should be considered a high-risk population for burn injury. This distinction serves as a call to action for the development of burn prevention strategies.
Article
Background Costs incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). Methods We conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. Results Our sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7–2.0]; RR 1.9 [95% CI,1.8–2.0]), missed appointments (RR 1.5 [95% CI,1.4–1.6]; RR 1.7 [95% CI,1.7–1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3–1.8]; RR 2.8 [95% CI,2.5–3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. Conclusions Social and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. Implications Future payment models should account for the health system resources required to care for populations with complex social and behavioral needs. Level of evidence IV.
Article
This study explores the stories of 40 homeless residents from a local shelter in El Paso, Texas located in the United States, with an emphasis on the socio-ecological factors (i.e. individual and environmental) leading to their homelessness. A total of 40 adult residents were recruited using purposive sampling between 2016 and 2017 to participate in an in-depth interview and a brief survey. Interview data were analysed using grounded theory method. Survey data were presented in the form of descriptive statistics. Overall, we found that contrary to the typical stereotypes that attribute the difficulties the homeless population faces to personal deficits (e.g. lack of motivation for upward mobility and maladaptive coping), many of our participants struggled with varying personal challenges and social constraints, which created a vulnerability to homelessness. Furthermore, inconsistent with the assumption that Hispanics are less susceptible to the concern of homelessness given their cultural and family orientations, we found that among our participants who were Hispanic, more than half had contact with family or friends and/or had at least one family member who was homeless, thus indicating that Hispanics are not free from the challenge of homelessness. This finding has public policy implications for U.S. cities that are predominantly Hispanic (of which El Paso is one), and cautions about the danger of overgeneralizing the homeless population. We noted five major life domains (legal, relational, economic, physiological, and psychiatric) that triggered the participants’ homelessness. Understanding factors leading to homelessness can form the basis for formulating effective intervention programmes that promote well-being, as well as a holistic roadmap that prioritizes strategies for sustainable healthy living.
Article
Introduction: Homeless patients tend to visit Emergency Departments (EDs) more frequently than the non-homeless population. The goal of this study was to assess differences in chief complaint, medical conditions, and disposition between homeless patients compared to non-homeless patients presenting to an urban ED. Methods: This was a retrospective cohort of homeless patients ages ≥18 years compared to non-homeless controls from January 1, 2017 to December 31, 2017. Exclusion criteria were as follows: direct admission to hospital floor, repeat visits, or leaving without being seen. The primary endpoint of this study was to assess differences in chief complaint of homeless versus non-homeless patients upon presentation to the ED. Our secondary endpoints included differences in ED utilization between the two groups, in terms of length of stay, ambulance use, diagnosis, and disposition. Results: Homeless patients were more likely present to the ED for a psychiatric evaluation (homeless group 34% vs. non-homeless group 4%, p < 0.01) and have a history of a psychiatric diagnosis (56% vs. 10%, p < 0.01) compared to non-homeless controls. Homeless patients also tended to require more ambulance transport (46% vs. 16%, p < 0.01). More homeless patients were transferred to a psychiatric facility (40% vs. 1%, p < 0.01), while the majority of non-homeless patients were discharged home (50% vs. 93%, p < 0.01). Conclusion: This study found that homeless patients had a significantly higher association with psychiatric diagnoses and greater ED utilization than non-homeless. This suggests the importance of increased access to consistent psychiatric care and follow up within the homeless population.
Article
Full-text available
Background Discharge delays for non-medical reasons put patients at unnecessary risk for hospital-acquired infections, lead to loss of revenue for hospitals and reduce hospital capacity to treat other patients. The objective of this study was to determine prevalence of, and patient characteristics associated with, delays in discharge at an urban county trauma service. Methods We performed a retrospective cohort study with data from Zuckerberg San Francisco General Hospital (ZSFGH), a level-1 trauma center and safety net hospital in San Francisco, California. The study included 1720 patients from the trauma surgery service at ZSFGH. A ‘delay in discharge’ was defined as days in the hospital, including an initial overnight stay, after all medical needs had been met. We used logistic and zero-inflated negative binomial regression models to test whether the following factors were associated with prolonged, non-medical length of stay: age, gender, race/ethnicity, housing, disposition location, type of insurance, having a primary care provider, primary language and zip code. Results Of the 1720 patients, 15% experienced a delay in discharge, for a total of 1147 days (median 1.5 days/patient). The following were statistically significant (p<0.05) predictors of delays in discharge in a multivariable logistic regression model: older age, unhoused status or disposition to home health or postacute care (compared with home discharge) were associated with increased likelihood of delays. Having private insurance or Medicare (compared with public insurance) and discharge against medical advice or absent without leave (compared with home discharge) were associated with reduced likelihood of delays in discharge after all medical needs were met. Discussion These results suggest that policymakers interested in reducing non-medical hospital stays should focus on addressing structural determinants of health, such as lack of housing, bottlenecks at postacute care disposition destinations and lack of adequate insurance. Level of evidence Epidemiological, Level III
Article
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.
Article
Objectives This study sought to (1) determine the number of persons evicted from the Durham Housing Authority (DHA) over a 5-year period, (2) explore changes in the number of persons with various medical diagnoses and health care utilization patterns before and after eviction, and (3) examine how many persons evicted from DHA became literally homeless. Design This was a pre/post cross-sectional quantitative study. Sample Heads of households evicted from DHA properties from January 1, 2013 through December 31, 2017 were included in the study. Measurements We matched people evicted by the DHA in a university health system electronic health record system to determine changes in diagnoses and health care utilization before and after eviction. We also matched the cohort in the homeless management information system to determine how many persons evicted became literally homeless. Results Findings indicate statistically significant increases in persons with medical diagnoses in five of ten categories, total hospital admissions, and emergency department visits after eviction. Of the 152 people included in the study, 34 (22%) became literally homeless. Conclusions Health and health care utilization patterns were different before and after eviction. Implications for clinicians are explored.
Article
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.
Article
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.
Article
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
Full-text available
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.
Article
Due to barriers in accessing and using healthcare services, a large proportion of the care homeless populations receive comes from informal providers. In Delhi, one such informal programme, called Street Medicine, provides healthcare outreach to homeless communities. Clinical practice guidelines are set to be developed for Street Medicine teams in India and form the object of this research. This study uses a social-ecological model to understand the barriers facing Street Medicine teams and the homeless as they attempt to address the latter’s healthcare needs; coupling it with an analytical approach which situates these barriers as the issues within practice through which standardisation can take place. A qualitative inquiry, comprising three months of observations of Street Medicine outreach and interviews with over 30 key informants, was conducted between April and July 2018. The analysis identified novel barriers to addressing the needs of homeless individuals, which bely a deficit between the design of health and social care systems and the agency homeless individuals possess within this system to influence their health outcomes. These barriers – which include user-dependent technological inscriptions, collaborating with untargeted providers and the distinct health needs of homeless individuals – are the entry points for standardising, or opening up, Street Medicine practices .
Article
Full-text available
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, −$19, −$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
Article
Full-text available
Background Improved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and increase the likelihood of a successful discharge home. Methods In this retrospective cohort study, we linked home care assessment records based on the Resident Assessment Instrument for Home Care (RAI-HC) of 210 931 hospitalised patients with their Discharge Abstract Database records. We then undertook multivariable logistic regression analyses to identify preadmission predictive factors for delayed discharge from hospital. Results Characteristics that predicted delayed discharge included advanced age (OR: 2.72, 95% CI 2.55 to 2.90), social vulnerability (OR: 1.27, 95% CI 1.08 to 1.49), Parkinsonism (OR: 1.34, 95% CI 1.28 to 1.41) Alzheimer’s disease and related dementias (OR: 1.27, 95% CI 1.23 to 1.31), need for long-term care facility services (OR: 2.08, 95% CI 1.96 to 2.21), difficulty in performing activities of daily living and instrumental activities of daily living, falls (OR: 1.16, 95% CI 1.12 to 1.19) and problematic behaviours such as wandering (OR: 1.29, 95% CI 1.22 to 1.38). Conclusion Predicting delayed discharge prior to or on admission is possible. Characteristics associated with delayed discharge and inability to return home are easily identified using existing interRAI home care assessments, which can then facilitate the targeting of pre-emptive interventions immediately on hospital admission.
Chapter
This section explores the challenges of discharging patients who are homeless and reviews solutions other cities have implemented to combat these issues. Homeless people experience poor access to healthcare, which can lead to delays in diagnosis and necessary care. It has a significant impact on hospitals and the course of treatment for these patients as they have a higher need for acute services and often longer and more expensive hospital stays. Without increased attention to these issues, including education for medical programs and financial support and resources, it will be challenging to provide the needed support to this population.
Chapter
Homeless individuals with chronic physical and mental illness often experience nonadherence to treatment interventions and lapses in access to healthcare. Compared to the general public, homeless individuals more often use emergency department services, experience longer hospital stays and suffer poorer treatment outcomes. This chapter will outline factors that are critical in understanding barriers to engagement and adherence among homeless individuals with severe mental illness. This chapter will discuss risk factors for nonadherence, barriers to adherence, consequences of nonadherence, and strategies to reduce nonadherence.
Chapter
Substance use disorders (SUDs) are more common among homeless persons, compared to those who are housed. There is bidirectional relationship between these disorders and homelessness, such that at times, SUD can lead to homelessness, and in other cases, homelessness can lead to SUD. In either case, homelessness is associated with more severe substance use, as well as significantly greater risk of multiple medical comorbidities, and poorer health outcomes, including suicide and other causes of mortality. This population can also present with concurrent serious mental illness, prominent trauma history, and/or PTSD. As a result, homeless persons with co-occurring SUD present significant challenges in clinical management. Initial efforts to work with this population will include community outreach and appropriate screening and assessment to identify these concerns early and offer services as soon as possible. Psychosocial interventions form the core of evidence-based treatments. Medications are available for some SUDs, but clinical management may require adaptations for use in homeless. Naloxone may be lifesaving for those with opioid use disorder. Acute hospitalization may be indicated for detoxification, and then intensive interventions, including residential programs, may be necessary post-discharge. The multi-pronged Chronic Care Model (CCM) has been successfully adapted to serving homeless persons with SUD, and can address such issues as stigma and chronicity, and offers an integrated care delivery system, to assure that comprehensive and wrap-around services are offered and made available to best serve this vulnerable population.
Article
Extended‐release opioids are often prescribed to manage postoperative pain despite being difficult to titrate to analgesic requirements and their association with long‐term opioid use. An Australian/New Zealand organisational position statement released in March 2018 recommended avoiding extended‐release opioid prescribing for acute pain. This study aimed to evaluate the impact of this organisational position statement on extended‐release opioid prescribing among surgical inpatients. Secondary objectives included predictors and clinical outcomes of prescribing extended‐release opioids among surgical inpatients. We conducted a retrospective, dual centre, 11‐month before‐and‐after study and time‐series analysis by utilising electronic medical records from two teaching hospitals in Sydney, Australia. The primary outcome was the proportion of patients prescribed an extended‐release opioid. For surgical patients prescribed any opioid (n = 16,284), extended‐release opioid prescribing decreased after the release of the position statement (38.4% before vs. 26.6% after, p < 0.001), primarily driven by a reduction in extended‐release oxycodone (31.1% before vs. 14.1% after, p < 0.001). There was a 23% immediate decline in extended‐release opioid prescribing after the position statement release (p < 0.001), followed by an additional 0.2% decline per month in the following months. Multivariable regression showed that the release of the position statement was associated with a decrease in extended‐release opioid prescribing (OR 0.54, 95%CI 0.50–0.58). Extended‐release opioid prescribing was also associated with increased incidence of opioid‐related adverse events (OR 1.52, 95%CI 1.35–1.71); length of stay (RR 1.44, 95%CI 1.39–1.51); and 28‐day re‐admission (OR 1.26, 95%CI 1.12–1.41). Overall, a reduction in extended‐release opioid prescribing was observed in surgical inpatients following position statement release.
Article
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.
Article
Objective To determine whether the homeless population experiences disparities in care and communication during inpatient hospitalizations in a safety-net hospital. Methods We administered a modified Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to 112 age-sex- and education matched homeless and non-homeless adults at a university-affiliated-safety-net hospital from December 2017 through March 2018 and performed a retrospective review of medical records. Linear regression models were used to assess differences in responses to survey subscales, length of stay and other measures. Results Homeless participants trended toward poorer ratings for all HCAHPS subscales, reaching significance for the Communication about Medications subscale, with a mean score 1.2 (95% CI 0.48–1.76) points lower compared to non-homeless sample. Length of stay was not significantly different between homeless and non-homeless participants. Conclusion In an urban safety-net hospital, disparities in communications regarding medications between hospital staff and patients were found based on housing status.
Article
The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.
Article
Compared with housed people, those experiencing homelessness have longer and more expensive inpatient stays as well as more frequent emergency department visits. Efforts to provide stable housing situations for people experiencing homelessness could reduce health care costs. Through the Supportive Services for Veteran Families program, the Department of Veterans Affairs partners with community organizations to provide temporary financial assistance to veterans who are currently homeless or at imminent risk of becoming homeless. We examined the impact of temporary financial assistance on health care costs for veterans in the Supportive Services for Veteran Families program and found that, on average, people receiving the assistance incurred $352 lower health care costs per quarter than those who did not receive the assistance. These results can inform national policy debates regarding the proper solution to housing instability.
Article
Full-text available
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.
Article
Full-text available
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 $242 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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
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 ($70,442 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.
Article
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.
Article
Homelessness is believed to be a cause of health problems and high medical costs, but data supporting this association have been difficult to obtain. We compared lengths of stay and reasons for hospital admission among homeless and other low-income persons in New York City to estimate the hospitalization costs associated with homelessness. We obtained hospital-discharge data on 18,864 admissions of homeless adults to New York City's public general hospitals (excluding admissions for childbirth) and 383,986 nonmaternity admissions of other low-income adults to all general hospitals in New York City during 1992 and 1993. The differences in length of stay were adjusted for diagnosis-related group, principal diagnosis, selected coexisting illnesses, and demographic characteristics. Of the admissions of homeless people, 51.5 percent were for treatment of substance abuse or mental illness, as compared with 22.8 percent for the other low-income patients, and another 19.7 percent of the admissions of homeless people were for trauma, respiratory disorders, skin disorders, and infectious diseases (excluding the acquired immunodeficiency syndrome [AIDS]), many of which are potentially preventable medical conditions. For the homeless, 80.6 percent of the admissions involved either a principal or a secondary diagnosis of substance abuse or mental illness -- roughly twice the rates for the other patients. The homeless patients stayed 4.1 days, or 36 percent, longer per admission on average than the other patients, even after adjustments were made for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The costs of the additional days per discharge averaged $4,094 for psychiatric patients, $3,370 for patients with AIDS, and $2,414 for all types of patients. Homelessness is associated with substantial excess costs per hospital stay in New York City. Decisions to fund housing and supportive services for the homeless should take into account the potential of these services to reduce the high costs of hospitalization in this population.
Article
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 (95% confidence interval $-93 to $3167; 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 ($101 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.
Article
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.
Case Mix Tools: For Decision Making in Health Care. Ottawa, ON: Canadian Institute for Health Information
  • L M Johnson
  • J Richards
  • G H Pink
Johnson LM, Richards J, Pink GH, et al, eds. Case Mix Tools: For Decision Making in Health Care. Ottawa, ON: Canadian Institute for Health Information; 1998.
Homelessness Partnering Strategy Available at
  • Human Resources
  • Skills Development Canada
Human Resources and Skills Development Canada. Homelessness Partnering Strategy. Available at: http://www.hrsdc.gc.ca/eng/ homelessness/index.shtml.
Alternate Level of Care. [Cancer Care Ontario web site
  • Cancer Care Ontario
Cancer Care Ontario. Alternate Level of Care. [Cancer Care Ontario web site]. Available at: http://www.cancercare.on.ca/ocs/alc. (Accessed December 2, 2009).
Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada. Ottawa, ON: Government of Canada, The Standing Senate Committee on Social Affairs
  • M Kirby
  • W Keon
Kirby M, Keon W. Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada. Ottawa, ON: Government of Canada, The Standing Senate Committee on Social Affairs, Science and Technology; 2006.
  • Toronto City Of
City of Toronto. 2009 Toronto Street Needs Assessment. Available at: http://www.toronto.ca/housing/about-streets-homes.htm.
Canada's mental health system
  • P Goering
  • D Wazylenki
  • J Durbin
Goering P, Wazylenki D, Durbin J. Canada's mental health system. Int J Law Psychiatry. 2000;23:345-359.
Economic evaluation of open versus endovascular repair of blunt traumatic thoracic aortic injuries
  • Mz Tong
  • P Koka
  • Tl Forbes
Tong MZ, Koka P, Forbes TL. Economic evaluation of open versus endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg. 2010;52:31-38.e3.