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Journal of Urban Health

, Volume 83, Issue 5, pp 860–873 | Cite as

Public Health Care Utilization in a Cohort of Homeless Adult Applicants to a Supportive Housing Program

  • Eric R. Kessell
  • Rajiv Bhatia
  • Joshua D. Bamberger
  • Margot B. KushelEmail author
Article

Abstract

Supportive housing is subsidized housing with on-site or closely linked services for chronically homeless persons. Most literature describing the effects of supportive housing on health service utilization does not describe use across multiple domains of services. We conducted a retrospective cohort study of 249 applicants to a supportive housing program; 114 (45.7%) were housed in the program. We describe the pattern of service use across multiple domains (housing, physical health care, mental health care, substance abuse treatment). We examine whether enrollment in supportive housing was associated with decreased use of acute health services (emergency department (ED) and inpatient medical hospitalizations) and increased use of ambulatory services (ambulatory medical and generalist care, mental health, and substance abuse treatment) as compared to those eligible but not enrolled. Participants in both groups exhibited high rates of service utilization. We did not find a difference in change in utilization patterns between the two groups [those that received housing (intervention) and those that applied, were eligible, but did not establish residency (usual care group)] comparing the two years prior to the intervention to the two years after. The finding of high rates of maintenance of housing is, in itself, noteworthy. The consistently high use of services across multiple domains and across multiple years speaks to the level of infirmity of this population and the costs of caring for its members.

Keywords

Health Homeless persons Housing Retrospective studies San Francisco Services. 

Notes

Acknowledgements

This research was supported by funds from the California Program on Access to Care (CPAC), California Policy Research Center, University of California, Grant Number #02GT13. The views and opinions expressed do not necessarily represent those of the Regents of the University of California, CPAC, its advisory board, or any State or County executive agency represented thereon. Other support included: San Francisco Department of Public Health (SFDPH) which provided salary support for Rajiv Bhatia and Eric Kessell (during the study design, data collection and analysis phases)

and the Agency for Healthcare Research and Quality grant K08 HS011415-03 and the Hellman Family Award for early career development provided salary support for Margot Kushel.

We acknowledge the assistance of the following individuals for assistance with obtaining the data used in the study:

Margot Antonetty, Daisy Leyva, Marc Trotz, SFDPH: Client Data, Supportive Housing Program data.

Bill McConnell, SFDPH, Mental Health Services and Substance Abuse Services Utilization data.

Mario Trevino, SFFD: Ambulance Service data.

Joe Goldenson, MD, SFDPH: Jail data.

References

  1. 1.
    Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331(5):304–309.PubMedCrossRefGoogle Scholar
  2. 2.
    Barrow SM, Herman DB, Cordova P, Struening EL. Mortality among homeless shelter residents in New York City. Am J Public Health. 1999;89(4):529–534.PubMedGoogle Scholar
  3. 3.
    Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283(16):2152–2157.PubMedCrossRefGoogle Scholar
  4. 4.
    Breakey WR, Fischer PJ, Kramer M, et al. Health and mental health problems of homeless men and women in Baltimore. JAMA. 1989;262(10):1352–1357.PubMedCrossRefGoogle Scholar
  5. 5.
    Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285(2):200–206.PubMedCrossRefGoogle Scholar
  6. 6.
    Kreider B, Nicholson S. Health insurance and the homeless. Health Econ. 1997;6(1):31–41.PubMedCrossRefGoogle Scholar
  7. 7.
    O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Utilization of health care services among subgroups of urban homeless and housed poor. J Health Polit Policy Law. 1999;24(1):91–114.PubMedGoogle Scholar
  8. 8.
    Padgett DK, Struening EL, Andrews H, Pittman J. Predictors of emergency room use by homeless adults in New York City: the influence of predisposing, enabling and need factors. Soc Sci Med. 1995;41(4):547–556.PubMedCrossRefGoogle Scholar
  9. 9.
    Padgett DK, Struening EL. Influence of substance abuse and mental disorders on emergency room use by homeless adults. Hosp Community Psychiatry. 1991;42(8):834–838.PubMedGoogle Scholar
  10. 10.
    Duchon LM, Weitzman BC, Shinn M. The relationship of residential instability to medical care utilization among poor mothers in New York City. Med Care. 1999;37(12):1282–1293.PubMedCrossRefGoogle Scholar
  11. 11.
    Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778–784.PubMedGoogle Scholar
  12. 12.
    Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department's frequent users. Acad Emerg Med. 2000;7(6):637–646.PubMedCrossRefGoogle Scholar
  13. 13.
    Palepu A, Strathdee SA, Hogg RS, et al. The social determinants of emergency department and hospital use by injection drug users in Canada. J Urban Health. 1999;76(4):409–418.PubMedCrossRefGoogle Scholar
  14. 14.
    D'Amore J, Hung O, Chiang W, Goldfrank L. The epidemiology of the homeless population and its impact on an urban emergency department. Acad Emerg Med. Nov 2001;8(11):1051–1055.PubMedCrossRefGoogle Scholar
  15. 15.
    Lipton FR, Siegel C, Hannigan A, Samuels J, Baker S. Tenure in supportive housing for homeless persons with severe mental illness. Psychiatr Serv. 2000;51(4):479–486.PubMedCrossRefGoogle Scholar
  16. 16.
    Rog D, Randolph F. A multisite evaluation of supported housing: lessons learned from cross-site collaboration. In: Herrell M, Straw R, eds. New Directions for Evaluations: No. 94. Conducting Multiple Site Evaluations in Real-world Settings. San Francisco: Jossey-Bass; 2002.Google Scholar
  17. 17.
    Culhane M, Hadley. The impact of supportive housing or homeless people with severe mental illness on the utilization of the public health, corrections, and emergency shelter systems: the New York-New York Initiative. Fannie Mae Foundation. May 2001:1–47.Google Scholar
  18. 18.
    Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000;34(6):1273–1302.PubMedGoogle Scholar
  19. 19.
    Heslin KC, Andersen RM, Gelberg L. Case management and access to services for homeless women. J Health Care Poor Underserved. 2003;14(1):34–51.PubMedCrossRefGoogle Scholar
  20. 20.
    Burton LC, Weiner JP, Stevens GD, et al. Health outcomes and medicaid costs for frail older individuals: a case study of a MCO versus fee-for-service care. J Am Geriatr Soc. 2002;50(2):382–388.PubMedCrossRefGoogle Scholar
  21. 21.
    Newcomer R, Maravilla V, Faculjak P, et al. Outcomes of preventive case management among high-risk elderly in three medical groups: a randomized controlled trial. Eval Health Prof. 2004;27(4):323–348.PubMedCrossRefGoogle Scholar
  22. 22.
    Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. J Am Geriatr Soc. 1999;47(7):775–783.PubMedGoogle Scholar
  23. 23.
    Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651–656.PubMedCrossRefGoogle Scholar
  24. 24.
    Culhane DP, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Hous Policy Debate. 2002;13(1):107–163.Google Scholar
  25. 25.
    Hastings SN, Heflin MT, Steele LS, et al. A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med. 2005;12(10):978–986.PubMedCrossRefGoogle Scholar
  26. 26.
    Dincin J, Wasmer D, Witheridge TF, Sobeck L, Cook J, Razzano L. Impact of assertive community treatment on the use of state hospital inpatient bed-days. Hosp Community Psychiatry 1993;44(9):833–838.PubMedGoogle Scholar
  27. 27.
    Wolff N, Helminiak TW, Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML. Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatr. 1997;154(3):341–348.PubMedGoogle Scholar
  28. 28.
    Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Serv. 2000;51(11):1410–1421.PubMedCrossRefGoogle Scholar
  29. 29.
    Salkever D, Domino ME, Burns BJ, et al. Assertive community treatment for people with severe mental illness: the effect on hospital use and costs. Health Serv Res. 1999;34(2):577–601.PubMedGoogle Scholar
  30. 30.
    Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med. 2002;162(6):705–712.PubMedCrossRefGoogle Scholar
  31. 31.
    Fitzgerald JF, Smith DM, Martin DK, Freedman JA, Katz BP. A case manager intervention to reduce readmissions. Arch Intern Med. 1994;154(15):1721–1729.PubMedCrossRefGoogle Scholar
  32. 32.
    Curtis JL, Millman EJ, Struening E, D'Ercole A. Effect of case management on rehospitalization and utilization of ambulatory care services. Hosp Community Psychiatr. 1992;43(9):895–899.PubMedGoogle Scholar
  33. 33.
    Rog DJ. The evidence on supported housing. Psychiatr Rehabil J. 2004;27(4):334–344.PubMedCrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2006

Authors and Affiliations

  • Eric R. Kessell
  • Rajiv Bhatia
  • Joshua D. Bamberger
  • Margot B. Kushel
    • 1
    Email author
  1. 1.Division of General Internal MedicineUCSF/San Francisco General HospitalSan FranciscoUSA

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