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Here’s Why You’re Treating More Homeless Patients

More than half a million people in the United States are homeless, and hospitalizations among this population are rising. Despite greater policy and public health focus over the last few decades, mental illness and substance use remain primary drivers of acute hospitalization among homeless adults, and may be the reason healthcare providers are seeing more homeless people in their practices. 

A homeless person is defined as one who lacks fixed and reliable housing. A new retrospective cohort study led by researchers from Beth Israel Deaconess Medical Center (BIDMC) and Brigham and Women’s Hospital examined the problem. They call for policy efforts to address barriers to the use of ambulatory care services, and behavioral health services in particular, to help reduce acute care use and improve the long-term health of homeless individuals.

What Did The Study Find?

The study examines patterns, causes and outcomes of acute hospitalizations between 2007 and 2013 for homeless individuals and non-homeless control groups in three populous and diverse U.S. states: Florida, California and Massachusetts. Data suggest a rise in acute hospital use among homeless individuals for mental illness and substance use disorder. The results were published in the journal Medical Care.

“The homeless population is aging, and the rate of hospitalizations for homeless individuals is increasing,” said lead author Rishi Wadhera, MD, an investigator in the Smith Center for Outcomes Research in Cardiology at BIDMC. “Although there has been a recent push to establish better policy and public health measures to improve the health of homeless adults, few studies have examined the patterns and causes of hospitalizations in this population. We found that hospitalizations among homeless adults tend to be for a very different set of conditions than non-homeless adults, even after accounting for differences in demographics.”

To examine these trends, hospital discharge data was acquired from Massachusetts and Florida between 2001 and 2013 and from California between 2007 and 2011. This information came from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project, created by the Agency for Healthcare Research and Quality. This dataset includes information such as homeless status, billing, demographics, and diagnoses. Hospitalization costs were determined by applying American Hospital Association cost-to-charge ratios to the total hospital charges provided in the SID.

Annual hospitalization rates for homeless persons were calculated and causes of hospitalization were compared with a demographics-standardized nonhomeless cohort. Logistic and linear regression models were used to estimate risk-standardized outcomes.

The study concluded that from 2007 to 2013, hospitalizations for the homeless increased in Massachusetts (294 to 420 hospitalizations per 1000 homeless residents), Florida (161 to 240/1000), and California (133 to 164/1000). Homeless patients were on average 46 years of age, often male (76.1%), white (62%), and either uninsured (41.9%) or insured by Medicaid (31.7%). Hospitalizations for homeless persons, compared with demographics-standardized nonhomeless, were more frequently for mental illness and substance use disorder (52% vs. 18%, P<0.001). Homeless compared with risk-standardized nonhomeless individuals had lower in-hospital mortality rates (0.9% vs. 1.2%, P<0.001), longer mean length of stay (6.5 vs. 5.9 d, P<0.001), and lower mean costs per day ($1 535 vs. $1 834, P<0.001).

What Do The Findings Mean?

“There is really is an urgent need to reduce financial and nonfinancial barriers to the use of ambulatory care, for behavioral health services in particular, to improve long-term management of physical and mental illness for the homeless,” said senior author Karen Joynt Maddox, MD, MPH, of Washington University in St. Louis. “We need better longitudinal data and further studies to understand how Medicaid expansion and other policy initiatives affect the health of this highly vulnerable population.”


Trends, Causes, and Outcomes of Hospitalizations for Homeless Individuals, Medical Care, American Public Health Association.

Last updated on 9/26/19.

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