High Utilizers of Emergency Health Services in a Population-Based Cohort of Homeless Adults

Chambers, Catharine; Chiu, Shirley; Katić, Marko; Kiss, Alex; Redelmeier, Donald A.; Levinson, Wendy; Hwang, Stephen W.

doi:10.2105/ajph.2013.301397

Cited by 107 publications

(103 citation statements)

References 49 publications

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“…14 A similar protective effect of immigrant status has been observed for emergency department visits. 34 Homeless participants who have a primary care provider tend to have a higher likelihood of medical/surgical hospitalization. This finding is contrary to studies of non-homeless populations that show that continuity of care may prevent hospitalization.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Medical or Surgical and Psychiatric Hospitalizations Among a Population-Based Cohort of Homeless Adults

et al. 2013

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Objectives-To identify factors associated with inpatient hospitalizations among a populationbased cohort of homeless adults in Toronto, Canada. Human Participant ProtectionThis study was approved by the Research Ethics Board at St. Michael's Hospital in Toronto, Canada. All participants provided written informed consent. NIH Public Access Author ManuscriptAm J Public Health. Author manuscript; available in PMC 2014 December 01. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptMethods-Participants were linked to administrative databases to capture hospital admissions during the study period (2005)(2006)(2007)(2008)(2009). Logistic regression was used to identify predictors of medical/surgical and psychiatric hospitalizations.Results-Among 1,165 homeless adults, 20% had a medical/surgical hospitalization and 12% had a psychiatric hospitalization during the study period. These individuals contributed a total of 921 hospitalizations, of which 548 were medical/surgical and 373 were psychiatric. Independent predictors of medical/surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization.Conclusions-Health care need was a strong predictor of medical/surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults are potentially avoidable, while others represent an unavoidable use of health services. KeywordsHospitalization; Homeless persons; Health care utilization Homeless adults are frequent users of inpatient hospital services. In a nationally representative sample of homeless persons in the United States, almost one in four respondents reported being hospitalized in the past year, a rate four times higher than U.S. norms. 1 The frequent use of inpatient hospital services partially reflects the high prevalence of acute and chronic disease, injuries and assaults, and substance use and mental illness among this population. [1][2][3] However, the high rates of hospitalization have also been attributed to a lack of access to primary and preventative care, particularly in the United States where 50% of homeless people have no health insurance. 1,[4][5][6][7] In a nationally representative sample of persons who used homeless services in the United States, Kushel et al. show that lack of health insurance and African American race/ethnicity, as compared to non-Latino white race/ethnicity, were the only factors significantly associated with a lower odds of self-reported hospitalization 1 In a subsequent study, Kushel et al. show that being uninsured significantly decreased the likelihood of self-reporting a non-maternal hospitalization in the past year, while food instability and housing instabilit...

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Section: Discussionmentioning

confidence: 99%

Predictors of Medical or Surgical and Psychiatric Hospitalizations Among a Population-Based Cohort of Homeless Adults

et al. 2013

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“…Homelessness is associated with significant health care needs and health complications, [1][2][3][4] often characterized by very high rates of emergency department use and inpatient hospitalizations [5][6][7] with an underutilizing of ambulatory care services. 8 Often the care provided can best be described as reactive to acute presentations: treating complications of homelessness such as frostbite or exposure-related illnesses; addressing acute complications of chronic conditions that are difficult to manage while homeless; and dealing with the consequences of untreated and undertreated mental health and substance abuse that often precipitate homelessness.…”

Section: Introductionmentioning

confidence: 99%

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial

et al. 2015

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BACKGROUND: Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. OBJECTIVE: We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. DESIGN: This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. PARTICIPANTS: Homeless Veterans not receiving primary care participated in the study. INTERVENTIONS: An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. MAIN MEASURE: We measured receipt of primary care within 4 weeks of study enrollment. KEY RESULTS: Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6 % were male, 43.0 % were from a minority population, 12.0 % were unsheltered, 25.5 % were staying in a dusk-to-dawn emergency shelter, 26.1 % were in transitional housing, while 27.7 % were in an unstable, doubled-up arrangement. At one month, 77.3 % of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7 % had been seen in primary care. This was followed by the CO-only group, 50.0 % of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0 % and the Usual Care arm at 30.6 %. Chi-squared tests by group were significant (p<0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. CONCLUSIONS: Our findings suggest that treatmentresistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.

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“…4,8 Disproportionate use of health care services by a segment of the population has been identified as a challenge in many countries, including Canada. [9][10][11][12] To encourage less resource-intensive care for frequent users, many efforts have been implemented. Some of these interventions, for example, have been designed specifically to transition health care utilization away from the hospital to other settings, such as community-based clinics.…”

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confidence: 99%

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis

Tricco

Antony

Ivers

et al. 2014

CMAJ

131

101

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Background: Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a metaanalysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. Methods:We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. Results:We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). Interpretation:We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management). AbstractSee related commentary, www.cmaj.ca/lookup

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High Utilizers of Emergency Health Services in a Population-Based Cohort of Homeless Adults

Cited by 107 publications

References 49 publications

Predictors of Medical or Surgical and Psychiatric Hospitalizations Among a Population-Based Cohort of Homeless Adults

Predictors of Medical or Surgical and Psychiatric Hospitalizations Among a Population-Based Cohort of Homeless Adults

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis

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