May 5, 2009 An intervention that provided housing and case management to homeless adults with chronic medical illnesses reduced hospitalizations and emergency department visits.
Addressing the health needs of the homeless population is a challenge to physicians, health institutions, and federal, state, and local governments, with an estimated 3.5 million individuals in the U.S. likely to experience homelessness in a given year. Rates of chronic medical illness are high among homeless adults, who are frequent users of costly emergency department and hospital services, largely paid for by public dollars. "The combination of chronic medical illnesses and poor access to primary health care has substantial health and economic consequences," the authors write.
Laura S. Sadowski, M.D., M.P.H., of Stroger Hospital of Cook County, Chicago, and colleagues conducted a study to determine whether an intervention that provided housing and case management for homeless adults with chronic medical illness would reduce hospitalizations and visits to the emergency department. Participants (n = 405; 78 percent men, 78 percent African American, with a median [midpoint] duration of homelessness of 30 months) were randomized to the intervention or usual care. The intervention (n = 201) included transitional housing after hospitalization discharge, followed by placement in long-term housing. Case managers facilitated the participant's housing placement and coordinated appropriate medical care, with substance abuse and mental health treatment referrals coordinated as needed. Usual care (n = 204) consisted of participants receiving standard discharge planning from hospital social workers.
After 18 months, 73 percent of participants had at least 1 hospitalization or emergency department visit. During this time period there were 583 hospitalizations in the intervention group (1.93 hospitalizations/person per year) and 743 in the usual care group (2.43 hospitalizations/person per year), with a reduction of 0.5 hospitalizations/person per year, and a reduction of 2.7 hospital days/person per year in the intervention group compared with the usual care group. Over 18 months, there were 2.61 emergency department visits/person per year in the intervention group and 3.77 visits/person per year in the usual care group, a reduction of 1.2 emergency department visits/person per year.
After adjusting for various factors, compared with the usual care group, the intervention group had a relative reduction of 29 percent in hospitalizations, 29 percent in hospital days and 24 percent in emergency department visits.
"Several factors could account for the success of our intervention. First, our case management program was linked to the medical system and provided coordinated services across the full spectrum of settings—hospitals, respite care centers, and stable and unstable community housing. Second, our intervention recognized the heterogeneity within the homeless population and tried to tailor the supportive housing to the participant's needs and characteristics. Third, our intervention represented a city-wide consortium of clinicians, social workers, and housing and other advocacy groups, which facilitated a comprehensive and coordinated effort to obtain case management and housing for every intervention participant."
"These results provide a rationale and a blueprint for programs that address the needs of this vulnerable population," the authors conclude.
Editorial: Housing the Chronically Homeless - High Hopes, Complex Realities
In an accompanying editorial, Stefan G. Kertesz, M.D., M.Sc., of the University of Alabama at Birmingham and Saul J. Weiner, M.D., of the University of Illinois at Chicago, write that the findings in this study and a study by Larimer et al, which appeared in the April 1, 2009 issue of JAMA, provide important information on the results of certain programs for the homeless.
"The studies by Larimer et al and Sadowski et al add to the increasing evidence that at least some large U.S. cities cannot afford not to house some who live on their streets. These studies demonstrate that for the most frequent users of costly public services, service use substantially abates when individuals have stable housing. The challenge now is to determine which subgroups of the homeless population could benefit most from Housing First, a valuable new approach—if not a panacea—in the quest to end homelessness."
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- Laura S. Sadowski; Romina A. Kee; Tyler J. VanderWeele; David Buchanan. Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults. JAMA, 2009;301(17):1771-1778 [link]
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