Hospitalization rates among homeless adults have increased sharply in recent years, with a very different set of causes from those in non-homeless individuals, reports a study in the January issue of Medical Care.
"Despite greater policy and public health focus over the last few decades, mental illness and substance use disorder still remain the primary drivers of acute hospitalizations among homeless adults," according to the new research, led by by Rishi Wadhera, MD, MPhil, of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical and Brigham and Women's Hospital, Boston. The authors discuss the implications for policies to improve healthcare and outcomes for homeless Americans.
Data from Three States Show 'Urgent Need' to Improve Care for Homeless Adults
The researchers assessed trends in hospital admissions for homeless adults from 2007 to 2013 in three states: Massachusetts, Florida, and California. The analysis included data on more than 185,000 hospitalizations for homeless individuals and 32 million admissions for non-homeless individuals. The two groups were standardized for demographic characteristics: average age was 46 years, 76 percent were male, and 62 percent were white.
All three states showed a significant increase in hospitalizations for homeless adults: from 294 to 420 per 1,000 homeless residents in Massachusetts, from 161 to 240 per 1,000 in Florida, and from 133 to 164 per 1,000 in California. Most homeless patients were uninsured (42 percent) or insured by Medicaid (32 percent).
Fifty-two percent of homeless patients were hospitalized for mental illness or substance use disorder, compared to 18 percent for non-homeless individuals. Other reasons for hospitalization were less likely in homeless individuals, including cardiovascular disease, gastrointestinal illness, and injury or poisoning.
Homeless individuals spent more days in the hospital—possibly because discharge decisions were affected by their lack of stable housing. They also had lower average costs of care, which may reflect differences in the intensity of care. In-hospital mortality was lower among homeless adults: 0.9 versus 1.2 percent.
"In the United States, an estimated 553,000 people are homeless on any given night," according to the authors. Recent years have seen intensified efforts to address the health of the homeless population, including Medicaid expansion and increased funding for healthcare centers and clinical services under the Affordable Care Act (ACA). Few studies have looked at how these policy initiatives have affected patterns of hospitalization among homeless people.
"We found that hospitalizations among homeless persons are rising," said Dr. Wadhera. "We think this is related to aging of the homeless population, and potentially, the rise of the opioid epidemic. Strikingly, more than half of hospitalizations for homeless adults were for mental health and substance use disorders, which we suspect reflects limited access to and coordination of behavioral health services." Expanded mental health and substance use disorder services under the ACA, as well as newer integrated healthcare delivery approaches, might help to improve provision of behavioral health services to homeless patients, the authors suggest.
"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 homeless individuals," 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."
More information: Rishi K. Wadhera et al. Trends, Causes, and Outcomes of Hospitalizations for Homeless Individuals, Medical Care (2018). DOI: 10.1097/MLR.0000000000001015