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Abramson TM, Burner E, Arora S, Wenzel S, Gausche-Hill M. Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors. PREHOSP EMERG CARE 2024:1-8. [PMID: 38771734 DOI: 10.1080/10903127.2024.2358146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis. METHODS We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023). RESULTS Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20). CONCLUSION In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.
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Affiliation(s)
- Tiffany M Abramson
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sanjay Arora
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Suzanne Wenzel
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County EMS Agency, Los Angeles, California
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Biomedical Innovation, Los Angeles, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Yoon J, Kim MJ, Kim KH, Park J, Shin DW, Kim H, Jeon W, Kim H, Kim J, Park JM. Characteristics of frequent emergency department users in Korea: a 4-year retrospective analysis using Korea Health Panel Study data. Clin Exp Emerg Med 2022; 9:114-119. [PMID: 35843611 PMCID: PMC9288872 DOI: 10.15441/ceem.21.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Objective We aimed to investigate the characteristics of frequent emergency department (ED) users in Korea. Methods We analyzed the Korea Health Panel Study data of a sampled population from the 2005 Population Census of Korea data, and adults (age ≥18 years) who visited the ED at least once a year between 2014 and 2017 were included in the study. People who visited three or more times a year were classified as frequent users. We compared demographic, socioeconomic, and health-related factors between nonfrequent and frequent users. We used a multivariable logistic regression analysis to determine factors related to frequent ED visits. We also compared the characteristics of ED use in both nonfrequent and frequent users. Results A total of 5,090 panels were included, comprising 6,853 visits. Frequent users were 333 (6.5% of all panels), and their ED visits were 1,364 (19.9% of all ED visits). In the multivariable regression analysis, medical aid coverage (adjusted odds ratio [aOR] of the National Health Service coverage, 0.55; 95% confidence interval [CI], 0.40–0.75), unemployment (aOR of employment, 0.72; 95% CI, 0.56–0.91), prior ward admission in a year (aOR, 2.14; 95% CI, 1.67–2.75), and frequent outpatient department use (aOR, 1.72; 95% CI, 1.35–2.20) were associated with frequent use. Moreover, frequent users visited the ED of public hospitals more often than than nonfrequent users (19.2% vs. 9.8%). Medical problems rather than injury/poisoning were the more common reasons for visiting the ED (84.5% vs. 71.2%). Conclusion We found that frequent ED users were likely to be those with socioeconomic disadvantage or with high demand for medical service. Based on this study, further studies on interventions to reduce frequent ED use are required for better ED services.
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Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services. Community Ment Health J 2021; 57:948-959. [PMID: 32734310 DOI: 10.1007/s10597-020-00693-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
This study identified profiles among 455 currently or formerly homeless individuals in Quebec (Canada), based on health and social service use. Using latent class analysis, four profiles were identified that grouped individuals with: (1) few health problems, and using few case managers and family doctors, but with high frequency of psychiatric consultations, emergency department (ED) visits and hospitalizations; (2) chronic physical illnesses, having case managers and family doctors, but low frequency of ED visits and hospitalizations; (3) moderate health problems and little service use; and (4) multiple and complex health problems and high frequency of service use. These profiles suggest the following recommendations to more adequately meet patient needs: regarding Class 1, improved outreach services, more ED liaison nurses and peer navigation; Class 2: more family doctors and case managers; Class 3: higher family doctors; and Class 4: more assertive or intensive case management, harm reduction and permanent housing resources.
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Werner BC, Bustos FP, Gean RP, Deasey MJ. Emergency Department Visits in the Year Prior to Total Shoulder Arthroplasty as a Risk Factor for Postoperative Emergency Department Visits. HSS J 2021; 17:200-206. [PMID: 34421431 PMCID: PMC8361596 DOI: 10.1177/1556331621995775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/04/2020] [Indexed: 11/17/2022]
Abstract
Background: Recent research has found a high rate of emergency department (ED) use after lower extremity arthroplasty; one study found a risk factor for ED presentation after lower extremity arthroplasty was presentation to the ED in the year prior to surgery. It is not known whether a similar association exists for total shoulder arthroplasty (TSA). Questions/Purposes: The goal of this study was to investigate the relationship between preoperative ED visits and postoperative ED visits after anatomic TSA. Methods: The 100% Medicare database was queried for patients who underwent anatomic TSA from 2005 to 2014. Emergency department visits within the year prior to the date of TSA were identified. Patients were additionally stratified by the number and timing of preoperative ED visits. The primary outcome measure was one or more postoperative ED visits within 90 days. A multivariate logistic regression analysis was used to control for patient demographics and comorbidities. Results: Of the 144,338 patients identified, 32,948 (22.8%) had an ED visit in the year prior to surgery. Patients with at least 1 ED visit in the year before surgery presented to the ED at a significantly higher rate than patients without preoperative ED visits (16% versus 6%). An ED visit in the year prior to TSA was the most significant risk factor for postoperative ED visits (in the multivariate analysis). The number of preoperative ED visits in the year prior to surgery demonstrated a significant dose-response relationship with increasing risk of postoperative ED visits. Conclusions: Postoperative ED visits occurred in nearly 10% of Medicare patients who underwent TSA in the period studied. More frequent presentation to the ED in the year prior to anatomic TSA was associated with increasing risk of postoperative ED visits. Future studies are needed to investigate the reasons for preoperative ED visits and if any modifiable risk factors are present to improve the ability to risk stratify and optimize patients for elective TSA.
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Affiliation(s)
- Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA,Brian C. Werner, MD, Department of Orthopaedic Surgery, University of Virginia Health System, P.O. Box 800159, Charlottesville, VA 22903, USA.
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Burak A, Cierzniakowska K, Popow A. Homeless people under the influence of alcohol admitted to hospital emergency departments in Poland. NORDIC STUDIES ON ALCOHOL AND DRUGS 2020; 37:190-200. [PMID: 32934601 PMCID: PMC7434175 DOI: 10.1177/1455072520908387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 01/20/2020] [Indexed: 11/21/2022] Open
Abstract
Aim: To assess the incidence of diagnoses related to alcohol use in the population of homeless people admitted to hospital emergency departments (EDs). Material and method: Data were analysed from three hospitals concerning stays of homeless people in three EDs in Bydgoszcz, Poland, in 2013–2015; 3133 stays were identified. The data were compiled using Microsoft Excel and Statistica 10 statistical software. Results: At the time of admission to EDs, 31% of homeless people were considered to be under the influence of alcohol. Diagnoses related to alcohol use accounted for 25% of all diagnoses. The average blood alcohol concentration in the patients was 2.97 per mille. The average blood alcohol concentration in the group of men was significantly higher than that in the group of women (p = 0.015). The average length of stay in the ED of patients under the influence of alcohol was significantly longer (p < 0.0001) than among sober patients. Conclusions: Homeless people under the influence of alcohol account for a third of the population of homeless patients admitted to hospital emergency departments, while alcohol-related ICD-10 diagnoses account for a fourth of all diagnoses in these patients. Homeless patients under the influence of alcohol stay longer in hospital emergency departments than do sober homeless people, which may translate into more frequent acts of aggression towards medical personnel. In Poland there are no systemic ED-level solutions as regards dealing with homeless patients for whom alcohol dependence is in many cases a reality.
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Affiliation(s)
- Anna Burak
- Nicolaus Copernicus University, Toruń, Poland
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Shukla DM, Faber EB, Sick B. Defining and Characterizing Frequent Attenders: Systematic Literature Review and Recommendations. J Patient Cent Res Rev 2020; 7:255-264. [PMID: 32760757 DOI: 10.17294/2330-0698.1747] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To decrease cost and improve efficiency, health care organizations have focused on frequent attenders - patients with high health care utilization. Prior studies have investigated singular health care settings, used varying definitions of frequent attendance, and inconsistently identified factors correlated with frequent attendance. The purpose of this article is to suggest a uniform definition of frequent attenders for different health care settings and to determine factors correlated with frequent attendance. METHODS This systematic review of three databases identified 2761 unique articles; 174 met inclusion criteria. Studies were analyzed for their definition of frequent attenders and factors associated with frequent attendance. RESULTS Most studies defined frequent attenders by number of health care visits within a set time period (n=115) and top percentile cutoff (n=42). Based on averages across studies, we propose the following frequent attender definitions: for primary care, either the top 10th percentile or at least 10 visits in 12 months; for emergency room, at least 5 visits in 12 months; and for inpatient hospitalization, at least 4 admissions in 12 months. Common factors correlated with frequent attendance were mental health and chronic disease. CONCLUSIONS We propose definitions of frequent attenders for three common health care settings: primary care, emergency room, and inpatient. Future studies should include mental health and chronic disease, among other factors, when studying this population. Adoption of these recommendations will allow comparisons across studies such that meta-analyses may better determine interventions for more appropriate health care utilization.
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Affiliation(s)
- Dip M Shukla
- University of Minnesota Medical School, Minneapolis, MN
| | - Erik B Faber
- University of Minnesota Medical School, Minneapolis, MN
| | - Brian Sick
- University of Minnesota Medical School, Minneapolis, MN
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Abramson TM, Sanko S, Eckstein M. Emergency Medical Services Utilization by Homeless Patients. PREHOSP EMERG CARE 2020; 25:333-340. [PMID: 32501745 DOI: 10.1080/10903127.2020.1777234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Homelessness is a rapidly growing issue throughout the United States and has important public health implications. Los Angeles, like other large urban cities, has seen a recent increase in homelessness. However, little is known about emergency medical service (EMS) utilization by those experiencing homelessness. Objective: Describe the utilization of emergency medical services by homeless patients. Methods: This is a 12-month retrospective review of electronic health records of all 911-incidents attended by the Los Angeles Fire Department (LAFD) from January to December 2018. The City of Los Angeles is 480 square miles and has a population of 3,949,776 with a homeless population of 31,285 (0.8% of city population). The primary outcome is the frequency of EMS 911-calls for homeless patients. Secondary outcomes include call characteristics. Results: There were 355,411 911-incidents during the study period. Homeless patients were involved in 36,122 (10.2%) incidents. Incidents for the homeless population occurred at a rate of 1155 per 1000 homeless residents or 14 times the rate of housed residents. Of the 217,972 calls resulting in transport to the emergency department, 28,917 (13.3%) were for homeless patients. This translates into a rate of 924 per 1000 homeless patients, which is 19 times higher than housed patients. Homeless patients were younger (mean 46.1 v 52.6 years) and more likely to be male (71% v 49.1%). Acuity was lower in the homeless group, 31.4% v 42.5% received advanced life support. Conclusion: In the City of Los Angeles, people experiencing homelessness demonstrated disproportionately high use of EMS services and ambulance transports, were more frequently younger, male, and had lower acuity conditions when compared with housed patients.
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El-Masri M, Bornais J, Omar A, Crawley J. Predictors of Nonurgent Emergency Visits at a Midsize Community-Based Hospital System: Secondary Analysis of Administrative Health Care Data. J Emerg Nurs 2020; 46:478-487. [DOI: 10.1016/j.jen.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 12/01/2022]
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Jiang L, Ye L, Dai M, Zhou J, Li Q. Use Andersen's behavior model to explain non-urgent visits in emergency department: A single center study in southwest China. Int Emerg Nurs 2020; 52:100845. [PMID: 32205107 DOI: 10.1016/j.ienj.2020.100845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/26/2019] [Accepted: 01/13/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-urgent ED visit was an important contributor of emergency overcrowding. Previous studies showed that patients make non-urgent ED visits for many reasons and their ED use patterns may be influenced by many factors. However, seldom studies were theory-based research aimed to offer a systemic insight regarding this question. METHODS This was a cross-sectional study conducted in the ED of a tertiary hospital in China guided by Andersen's behavior model of health service use. Patients triaged as non-urgent were surveyed using a self-administrated questionnaire to investigate the reasons for ED presentation and associated factors influenced their ED use patterns. RESULTS Perceived severity of illness and urgent treatment need (374, 68.6%), accessible problems to alternative services (144, 26.4%) and referral by medical staffs (134, 24.6%) were most commonly reported reasons for ED presentation. Alternative service attempt before ED presentation was determined by two predisposing factors: education level (OR = 0.638, P < 0.05) and use of nearest medical institution (OR = 1.588, P < 0.05). Prior non-urgent ED use was explained by both predisposing and need factors. They were: nationality (OR = 3.057, P < 0.01), type of health problems (OR = 1.641, P < 0.01) and self-rated health status (OR = 0.769, P < 0.01). CONCLUSION Patients' perceived need of emergency care played an extremely important role in driving ED use although several factors were identified. Future studies aim to decrease non-urgent ED use in China may firstly gain success from patient education programs.
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Affiliation(s)
- Lingjun Jiang
- Department of Emergency Medicine/Institute of Disaster Medicine, West China Hospital, Sichuan University, China; West China School of Nursing, West China Hospital, Sichuan University, China
| | - Lei Ye
- Department of Emergency Medicine/Institute of Disaster Medicine, West China Hospital, Sichuan University, China.
| | - Min Dai
- Department of Emergency Medicine/Institute of Disaster Medicine, West China Hospital, Sichuan University, China
| | - Jing Zhou
- Department of Emergency Medicine/Institute of Disaster Medicine, West China Hospital, Sichuan University, China
| | - Qin Li
- Department of Emergency Medicine/Institute of Disaster Medicine, West China Hospital, Sichuan University, China
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Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol 2019; 71:2585-2597. [PMID: 29852981 DOI: 10.1016/j.jacc.2018.02.077] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 01/14/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Samantha S Liauw
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
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Schrader CD, Robinson RD, Blair S, Shaikh S, Ho AF, D'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H. Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study. BMC Health Serv Res 2019; 19:451. [PMID: 31272442 PMCID: PMC6610992 DOI: 10.1186/s12913-019-4300-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients. Methods This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions. Result A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001). Conclusions Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations. Electronic supplementary material The online version of this article (10.1186/s12913-019-4300-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA.,Department of Medical Education, UNTHSC, Fort Worth, TX, 76104, USA
| | - Somer Blair
- Office of Clinical Research, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Sajid Shaikh
- Department of Information Technology, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Amy F Ho
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - James P D'Etienne
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Jessica J Kirby
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Radhika Cheeti
- Department of Information Technology, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA.
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Gabbard MD, Charters MA, Mahoney SP, North WT. Emergency Department Visit Within One Year Prior to Elective Total Joint Arthroplasty Is Predictive of Postoperative Return to Emergency Department Within 90 Days. J Arthroplasty 2019; 34:S97-S101. [PMID: 30982762 DOI: 10.1016/j.arth.2019.03.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement Model, developed by Centers for Medicare and Medicaid Services, aims to improve the quality of joint replacement. Metrics including emergency room visit rates after primary total knee and total hip arthroplasty (TKA and THA) are of particular interest. The purpose of this study is to determine if preoperative emergency department (ED) visits are predictive of postoperative ED visits among patients undergoing elective THA or TKA. METHODS In a retrospective analysis of 6996 patients who underwent elective primary arthroplasty (2453 hips, 4543 knees), we identified all patients who had an ED visit from up to 1 year prior to their surgical date to 90 days after. We assessed if preoperative visit frequency or temporality is predictive of a return to the ED visit within 90 days. RESULTS TKA and THA patients with a single preoperative ED visit had an odds ratio of 1.9 and 2.0, respectively, of returning to the emergency room postoperatively (P < .001). Increasing preoperative visit frequency correlated with increasing odds ratios (1.9-16.7, P < .001). The proximity of the most recent preoperative visit prior to surgery had a positive trend toward a larger effect, but did not clearly demonstrate a dose-dependent effect. CONCLUSION Presentation to the ED is common prior to total joint arthroplasty and is predictive of a postoperative visit within 90 days. Increasing preoperative visit frequency further increases a patient's risk of a postoperative visit within 90 days.
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Affiliation(s)
- Michael D Gabbard
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Michael A Charters
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Sean P Mahoney
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Wayne T North
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
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Miyazawa A, Maeno T, Shaku F, Tsutsumi M, Kurihara H, Takayashiki A, Kohno M, Suzuki M, Maeno T. Inappropriate use of the emergency department for nonurgent conditions: Patient characteristics and associated factors at a Japanese hospital. J Gen Fam Med 2019; 20:146-153. [PMID: 31312581 PMCID: PMC6612776 DOI: 10.1002/jgf2.249] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 03/16/2019] [Accepted: 03/28/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the primary factors associated with inappropriate out-of-hours emergency department (ED) use by patients with nonurgent conditions. METHODS We compared patients with nonurgent conditions who made inappropriate, out-of-hours ED visits to patients who visited an acute care hospital during daytime consultation hours between May 30 and October 16, 2014, in terms of patient characteristics and reasons for consultation. Our goal was to identify factors associated with inappropriate ED use, defined as an out-of-hours, nonurgent, and unnecessary visits. RESULTS We analyzed data from 84 patients who made inappropriate use of out-of-hours emergency care and 147 patients who sought care during regular consultation hours. In the inappropriate use group, "desire to be cured quickly" was the most common reason. Acute upper respiratory infection, acute gastroenteritis, and primary headache comprised 51.1% of diagnoses in the inappropriate use group. One factor associated with inappropriate use was two or more previous out-of-hours ED visits (odds ratio (OR) 3.19; 95% confidence interval (CI) 1.22-8.31) (reference: 0 visits). CONCLUSIONS Patients with two or more previous out-of-hours ED visits were more than three times as likely to inappropriately use the ED compared to patients who had not visited the ED at all in the past 3 years.
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Affiliation(s)
- Asako Miyazawa
- Department of Primary care and Medical EducationDoctoral Program in Clinical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Takami Maeno
- Department of Primary care and Medical EducationFaculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Fumio Shaku
- Department of Psychosomatic Internal MedicineNihon University Itabashi HospitalTokyoJapan
| | | | | | - Ayumi Takayashiki
- Department of Primary care and Medical EducationFaculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Mototsugu Kohno
- Department of Emergency MedicineTsukuba Medical Center HospitalTsukubaIbarakiJapan
| | - Masatsune Suzuki
- Department of Postgraduate EducationTsukuba Medical Center HospitalTsukubaIbarakiJapan
| | - Tetsuhiro Maeno
- Department of Primary care and Medical EducationFaculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
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Kaduszkiewicz H, Bochon B, van den Bussche H, Hansmann-Wiest J, van der Leeden C. The Medical Treatment of Homeless People. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:673-679. [PMID: 29070427 DOI: 10.3238/arztebl.2017.0673] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 06/28/2017] [Accepted: 09/01/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The homeless are often in poor health, and their risk of premature death is three to four times that of the general population. This article is intended to provide an overview of the medical care of the homeless in Germany. METHODS We selectively reviewed pertinent scientific and non-scientific publications from the years 2000-2017 that were retrieved from PubMed, from the reports of the German Homeless Aid Society (Bundesarbeitsgemeinschaft Wohnungslosenhilfe), from the websites of homeless aid organizations, and from Google Scholar. RESULTS At least 75% of the homeless currently suffer from a mental illness requiring treatment. Common somatic problems include respiratory (6-14%) and cardiovascular disorders (7-20%), injuries and intoxications (5-15%), and infectious and parasitic diseases (10-16%). To circumvent the multiple barriers impeding homeless people's access to standard medical care (lack of health insurance, a feeling of being unwelcome, lack of disease awareness, impaired capacity for compliance), medical help is offered to them outside the system in a number of ways, embedded in an overall scheme of social and practical assistance with daily living. These medical resources differ from region to region. They are often underfinanced and tend to focus on acute general medical care, with limited access to specialists. CONCLUSION More heath care resources need to be made available to the homeless beyond standard medical care. Concrete suggestions are discussed in the text.
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Affiliation(s)
- Hanna Kaduszkiewicz
- Institute of General Practice, Faculty of Medicine, Christian-Albrechts-Universität zu Kiel; Universitätsklinikum Hamburg-Eppendorf (UKE), Department of Primary Medical Care
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O'Toole TP, Johnson EE, Borgia M, Noack A, Yoon J, Gehlert E, Lo J. Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial. Prev Chronic Dis 2018; 15:E23. [PMID: 29451116 PMCID: PMC5814153 DOI: 10.5888/pcd15.170311] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Although traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH. Methods We conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014. Results Compared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better. Conclusion Homeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.
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Affiliation(s)
- Thomas P O'Toole
- National Center on Homelessness Among Veterans, US Veterans Health Administration, Providence, Rhode Island.,National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02908. .,Alpert Medical School at Brown University, Providence, Rhode Island
| | - Erin E Johnson
- National Center on Homelessness Among Veterans, US Veterans Health Administration, Providence, Rhode Island.,Providence VA Medical Center, Providence, Rhode Island
| | | | - Amy Noack
- San Francisco VA Medical Center, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Jean Yoon
- VA Palo Alto Health Care System, Palo Alto, California
| | | | - Jeanie Lo
- VA Palo Alto Health Care System, Palo Alto, California
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Jones AL, Thomas R, Hedayati DO, Saba SK, Conley J, Gordon AJ. Patient predictors and utilization of health services within a medical home for homeless persons. Subst Abus 2018; 39:354-360. [PMID: 29412071 DOI: 10.1080/08897077.2018.1437500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Veterans Health Administration (VHA) established a patient-centered medical home model of care for veterans experiencing homelessness called a Homeless Patient Aligned Care Team (HPACT) to improve engagement with primary care and reduce utilization of hospital-based services. To evaluate the impact of the HPACT model, this study compares the number and type of health care visits in the 12 months before and after enrollment in HPACT at one VHA facility, and explores patient characteristics associated with increases and decreases in visits. METHODS Chart reviews of VHA medical records were conducted for all patients enrolled in an HPACT in Pittsburgh, Pennsylvania, between May 2012 and December 2013 (N = 179). Multivariable mixed-effect logistic regressions estimated differences in having any visit in the 0-6 months and 7-12 months before and after HPACT enrollment, and multinomial logistic regressions predicted increases or decreases versus no change in number of visits over 12 months. RESULTS Compared with 0-6 months prior to HPACT, patients were more likely to visit primary care in the 0-6 months (adjusted odds ratio [aOR] = 4.91, 95% confidence interval [CI] = 2.94-8.20) and 7-12 months (aOR = 2.30, 95% CI = 1.42-3.72) following HPACT. Patients were less likely to visit the emergency department (ED) or to be hospitalized in the 0-6 months (aOR = 0.57, 95% CI = 0.34-0.94; and aOR = 0.55, 95% CI = 0.25-0.76) and 7-12 months (aOR = 0.43, 95% CI = 0.33-0.91; and aOR = 0.45, 95% CI = 0.26-0.80) following HPACT. Patients were less likely to visit mental health (aOR = 0.35, 95% CI = 0.20-0.60) and addiction specialists (aOR = 0.39, 95% CI = 0.18-0.84) in the 7-12 months following HPACT. Overall, 59% of patients had increases in primary care visits following HPACT. Female patients and those with self-housing were less likely to have increases versus no change in primary care visits (adjusted relative risk ratio [aRRR] = 0.15, 95% CI = 0.03-0.74; and aRRR = 0.35, 95% CI = 0.14-0.90). CONCLUSIONS An integrated HPACT model was successful in engaging homeless veterans in primary care for 1 year, potentially contributing to reductions in ED use. More tailored approaches may be needed for vulnerable populations experiencing homelessness, including homeless women.
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Affiliation(s)
- Audrey L Jones
- a Informatics , Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center of Innovation, VA Salt Lake City Health Care System , Salt Lake City , Utah , USA.,b Department of Internal Medicine , University of Utah School of Medicine , Salt Lake City , Utah , USA
| | - Roxanne Thomas
- c Providence Milwaukie Hospital , Milwaukie , Oregon , USA
| | | | - Shaddy K Saba
- e Center for Health Equity Research and Promotion (CHERP) , VA Pittsburgh Healthcare System , Pittsburgh , Pennsylvania , USA
| | - James Conley
- e Center for Health Equity Research and Promotion (CHERP) , VA Pittsburgh Healthcare System , Pittsburgh , Pennsylvania , USA
| | - Adam J Gordon
- a Informatics , Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center of Innovation, VA Salt Lake City Health Care System , Salt Lake City , Utah , USA.,b Department of Internal Medicine , University of Utah School of Medicine , Salt Lake City , Utah , USA.,f Department of Psychiatry , University of Utah School of Medicine , Salt Lake City , Utah , USA
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Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care. Med Care 2017; 55 Suppl 9 Suppl 2:S104-S110. [DOI: 10.1097/mlr.0000000000000770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Landefeld JC, Miaskowski C, Tieu L, Ponath C, Lee CT, Guzman D, Kushel M. Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study. THE JOURNAL OF PAIN 2017; 18:1036-1045. [PMID: 28412229 PMCID: PMC5581208 DOI: 10.1016/j.jpain.2017.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/16/2017] [Accepted: 03/28/2017] [Indexed: 12/22/2022]
Abstract
Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness. PERSPECTIVE This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.
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Affiliation(s)
- John C Landefeld
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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Raven MC, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study. Acad Emerg Med 2017; 24:63-74. [PMID: 27520382 DOI: 10.1111/acem.13070] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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Affiliation(s)
- Maria C. Raven
- Department of Emergency Medicine University of California at San Francisco San Francisco CA
- Philip R. Lee Institute for Health Policy Studies University of California at San Francisco San Francisco CA
| | - Lina Tieu
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Christopher T. Lee
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Claudia Ponath
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - David Guzman
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Margot Kushel
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
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Demographic factors influencing nonurgent emergency department utilization among a Medicaid population. Health Care Manag Sci 2016; 20:395-402. [PMID: 26924799 DOI: 10.1007/s10729-016-9360-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/01/2016] [Indexed: 01/24/2023]
Abstract
To use administrative medical encounter data to examine nonurgent emergency department (ED) utilization as it relates to member characteristics (i.e., age, gender, race/ethnicity, urbanicity and federal poverty level (FPL)). This 1 year cross-sectional study used medical claims from a managed care organization for Medicaid members enrolled from October 1, 2010 - September 30, 2011. ED encounters occurring during the study period were classified as either urgent or nonurgent using ICD-9 diagnosis codes obtained from medical claims. Examples of urgent diagnoses include head traumas, burns, allergic reactions, poisonings, preterm labor or maternal/fetal distress. A total of 187,263 members aged 2 to 65 years were retained for study. A zero-inflated Poisson regression model examined the influence of member-level characteristics on nonurgent ED utilization, while simultaneously adjusting for all factors. Females were 41 % more likely to have a nonurgent ED visit (p ≤ 0.0001). Members ages 50-65 were least likely to have a nonurgent ED visit (p ≤ 0.0001). White members had higher odds of having at least one nonurgent ED visit (p ≤ 0.0002). Rural members were 7.7 % less likely to have a nonurgent ED visit. Members in the 400 % + FPL category were less likely to seek nonurgent care from an ED (p ≤ 0.0001). A nonurgent ED visit occurs when care is sought at an ED that could have been handled in a primary care setting. Approximately 30-50 % of all ED visits in the United States are considered nonurgent. This study supports the need to determine factors associated with misuse of ED services for nonurgent care. Demographic factors significantly impacting nonurgent ED utilization include gender, age, race/ethnicity, urbanicity and percent of the FPL. Results may be useful in ED utilization management efforts.
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The Role of Charity Care and Primary Care Physician Assignment on ED Use in Homeless Patients. Am J Emerg Med 2015; 33:1006-11. [DOI: 10.1016/j.ajem.2015.04.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 11/20/2022] Open
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Chen BK, Hibbert J, Cheng X, Bennett K. Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006-2010: an observational study. Int J Equity Health 2015; 14:30. [PMID: 25889646 PMCID: PMC4391132 DOI: 10.1186/s12939-015-0158-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 02/26/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Use of the hospital emergency department (ED) for medical conditions not likely to require immediate treatment is a controversial topic. It has been faulted for ED overcrowding, increased expenditures, and decreased quality of care. On the other hand, such avoidable ED utilization may be a manifestation of barriers to primary care access. METHODS A random 10% subsample of all ED visits with unmasked variables, or approximately 7.2% of all ED visits in California between 2006 and 2010 are used in the analysis. Using panel data methods, we employ linear probability and fractional probit models with hospital fixed effects to analyze the associations between avoidable ED utilization in California and observable patient characteristics. We also test whether shorter estimated road distances to the hospital ED are correlated with non-urgent ED utilization, as defined by the New York University ED Algorithm. We then investigate whether proximity of a Federally Qualified Health Center (FQHC) is correlated with reductions in non-urgent ED utilization among Medicaid patients. RESULTS We find that relative to the reference group of adults aged 35-64, younger patients generally have higher scores for non-urgent conditions and lower scores for urgent conditions. However, elderly patients (≥65) use the ED for conditions more likely to be urgent. Relative to male and white patients, respectively, female patients and all identified racial and ethnic minorities use the ED for conditions more likely to be non-urgent. Patients with non-commercial insurance coverage also use the ED for conditions more likely to be non-urgent. Medicare and Medicaid patients who live closer to the hospital ED have higher probability scores for non-emergent visits. However, among Medicaid enrollees, those who live in zip codes with an FQHC within 0.5 mile of the zip code population centroid visit the ED for medical conditions less likely to be non-emergent. CONCLUSIONS These patterns of ED utilization point to potential barriers to care among historically vulnerable groups, observable even when using rough estimates of travel distances and avoidable ED utilization.
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Affiliation(s)
- Brian K Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC, 29208, USA.
| | - James Hibbert
- Center for Research in Nutrition and Health Disparities, University of South Carolina, 921 Assembly Street #230, Columbia, SC, 29208, USA.
| | - Xi Cheng
- Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA.
| | - Kevin Bennett
- Family and Preventive Medicine, University of South Carolina School of Medicine, 3209 Colonial Dr., Columbia, SC, 29203, USA.
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Abstract
Data from the 2009-2010 National Hospital Ambulatory Care Survey-Emergency Department were used to compare homeless patients' utilization of the urban emergency department (ED) in the United States with nonhomeless patients and to examine the relationship between homelessness and demographics and ED utilization measures. The weighted sample size was 200 645 347. A total of 1 302 256 patients (0.65%) were homeless. Homeless patients were significantly more likely to be older, male, have self-pay, have no charge/charity or other as payment type, arrive via ambulance, have a longer ED visit, and a past visit to the same ED in the last year.
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Mackelprang JL, Collins SE, Clifasefi SL. Housing First is associated with reduced use of emergency medical services. PREHOSP EMERG CARE 2014; 18:476-82. [PMID: 24878364 PMCID: PMC5102506 DOI: 10.3109/10903127.2014.916020] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Chronically homeless adults with severe alcohol problems are disproportionately burdened with health-care problems and are high utilizers of emergency medical services (EMS). Single-site Housing First (HF), which provides immediate, permanent, low-barrier, nonabstinence-based, supportive housing, has been associated with reduced publicly funded service utilization. The aims of the current study were to determine whether time spent in single-site HF predicted decreases in EMS contacts 2 years subsequent to single-site HF move-in, and to describe medical conditions and injuries associated with EMS contacts in a sample of chronically homeless individuals with severe alcohol problems. METHODS Participants were 91 chronically homeless adults with severe alcohol problems who were enrolled in a single-site HF program between December 2005 and March 2007 in Seattle, Washington. We obtained administrative data on exposure to HF and EMS utilization for the 2 years prior to and the 2 years subsequent to participants' move-in date. EMS utilization variables included patient type (i.e., primary presenting problem), trauma/injury mechanism (i.e., EMS classification of the cause of the trauma or injury), level of care (i.e., basic life support, advanced life support), and transport destination. RESULTS After controlling for baseline EMS contacts, participants evinced 3% fewer EMS contacts for each additional month of single-site HF exposure. From the baseline to follow-up period, the mean number of EMS contacts declined from 15.85 (SD = 22.96) to 9.54 (SD = 15.08), representing a 54% reduction in the number of EMS contacts. Most calls were responded to by EMTs providing basic life support, and the majority resulted in transport to a local level I trauma center. The most common presenting difficulties were medical illness and trauma. Substance use and psychiatric difficulties were infrequently documented as the primary problem. CONCLUSIONS Our findings support recent assertions that housing is health care and indicate that the amount of time spent in single-site HF is associated with significant reductions in EMS utilization for at least 2 years subsequent to move-in. These findings also underscore the high levels of medical illness and trauma exposure among chronically homeless adults with severe alcohol problems.
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Development of the Primary Care Quality-Homeless (PCQ-H) instrument: a practical survey of homeless patients' experiences in primary care. Med Care 2014; 52:734-42. [PMID: 25023918 DOI: 10.1097/mlr.0000000000000160] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. OBJECTIVES This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients; and (b) the methods utilized in its development. METHODS Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function (TIF) curves to eliminate less informative items and devise plausibly distinct subscales. RESULTS The resulting 33-item instrument (Primary Care Quality-Homeless) has 4 subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items), and Homeless-specific Needs (4 items). Evidence for divergent and convergent validity is provided. TIF graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation, and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (α=0.75) and patients frequently reported problems in this aspect of care. CONCLUSIONS Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.
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Skosireva A, O'Campo P, Zerger S, Chambers C, Gapka S, Stergiopoulos V. Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings. BMC Health Serv Res 2014; 14:376. [PMID: 25196184 PMCID: PMC4176588 DOI: 10.1186/1472-6963-14-376] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 09/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research on discrimination in healthcare settings has primarily focused on health implications of race-based discrimination among ethno-racial minority groups. Little is known about discrimination experiences of other marginalized populations, particularly groups facing multiple disadvantages who may be subjected to other/multiple forms of discrimination. OBJECTIVES (1) To examine the prevalence of perceived discrimination due to homelessness/poverty, mental illness/alcohol/drug related problems, and race/ethnicity/skin color while seeking healthcare in the past year among racially diverse homeless adults with mental illness; (2) To identify whether perceiving certain types of discrimination is associated with increased likelihood of perceiving other kinds of discrimination; and (3) To examine association of these perceived discrimination experiences with socio-demographic characteristics, self-reported measures of psychiatric symptomatology and substance use, and Emergency Department utilization. METHODS We used baseline data from the Toronto site of the At Home/Chez Soi randomized controlled trial of Housing First for homeless adults with mental illness (n = 550). Bivariate statistics and multivariable logistic regression models were used for the analysis. RESULTS Perceived discrimination related to homelessness/poverty (30.4%) and mental illness/alcohol/substance use (32.5%) is prevalent among ethnically diverse homeless adults with mental illness in healthcare settings. Only 15% of the total participants reported discrimination due to race/ethnicity/skin color. After controlling for relevant confounders and presence of psychosis, all types of discrimination in healthcare settings were associated with more frequent ED use, a greater - 3 - severity of lifetime substance abuse, and mental health problems. Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination. CONCLUSIONS Understanding the experience of discrimination in healthcare settings and associated healthcare utilization is the first step towards designing policies and interventions to address health disparities among vulnerable populations. This study contributes to the knowledge base in this important area. TRIAL REGISTRATION NUMBER This study has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374.
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Affiliation(s)
| | | | | | | | | | - Vicky Stergiopoulos
- Centre for Research on Inner City Health, Li Ka-Shing Knowledge Institute, Keenan Research, Centre, St, Michael's Hospital, Toronto, Canada.
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Hwang SW, Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W. A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. Am J Public Health 2013; 103 Suppl 2:S294-301. [PMID: 24148051 PMCID: PMC3969141 DOI: 10.2105/ajph.2013.301369] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. METHODS We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). RESULTS Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. CONCLUSIONS In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
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Affiliation(s)
- Stephen W Hwang
- Stephen W. Hwang, Catharine Chambers, and Shirley Chiu are with the Centre for Research on Inner City Health, part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto
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O'Toole TP, Bourgault C, Johnson EE, Redihan SG, Borgia M, Aiello R, Kane V. New to care: demands on a health system when homeless veterans are enrolled in a medical home model. Am J Public Health 2013; 103 Suppl 2:S374-9. [PMID: 24148042 DOI: 10.2105/ajph.2013.301632] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. METHODS We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. RESULTS We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. CONCLUSIONS Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.
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Affiliation(s)
- Thomas P O'Toole
- Thomas P. O'Toole, Claire Bourgault, Erin E. Johnson, Stephen G. Redihan, and Matthew Borgia are with the Providence Veterans Affairs (VA) Medical Center, Warren Alpert Medical School at Brown University, and VA National Center on Homelessness Among Veterans, Providence, RI. Riccardo Aiello and Vincent Kane are with the National Center on Homeless Among Veterans, Providence. Vincent Kane is also a guest editor for this supplement issue
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Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W, Hwang SW. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health 2013; 103 Suppl 2:S302-10. [PMID: 24148033 DOI: 10.2105/ajph.2013.301397] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. METHODS We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005-2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). RESULTS Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. CONCLUSIONS Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors.
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Affiliation(s)
- Catharine Chambers
- Catharine Chambers, Shirley Chiu, and Stephen W. Hwang are with the Centre for Research on Inner City Health, the Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto, Toronto
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Lebrun-Harris LA, Baggett TP, Jenkins DM, Sripipatana A, Sharma R, Hayashi AS, Daly CA, Ngo-Metzger Q. Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey. Health Serv Res 2012; 48:992-1017. [PMID: 23134588 DOI: 10.1111/1475-6773.12009] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts. DATA SOURCES/STUDY SETTING Nationally representative data from the 2009 Health Center Patient Survey. STUDY DESIGN Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients' health care experiences. DATA COLLECTION Computer-assisted personal interviews were conducted with health center patients. PRINCIPAL FINDINGS Homeless patients had worse health status-lifetime burden of chronic conditions, mental health problems, and substance use problems-compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24-3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37-2.92). CONCLUSIONS There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.
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Affiliation(s)
- Lydie A Lebrun-Harris
- US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care, Rockville, MD 20857, USA.
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Greysen SR, Allen R, Lucas GI, Wang EA, Rosenthal MS. Understanding transitions in care from hospital to homeless shelter: a mixed-methods, community-based participatory approach. J Gen Intern Med 2012; 27:1484-91. [PMID: 22707359 PMCID: PMC3475815 DOI: 10.1007/s11606-012-2117-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/24/2012] [Accepted: 05/01/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking. OBJECTIVES To understand patients' experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions. DESIGNS Mixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter. PARTICIPANTS Ninety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year. APPROACH Using semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients' perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients' perspective. KEY RESULTS Using qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44 % of participants reported that housing status was assessed and 42 % reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11 % reported staying on the streets with no shelter on the first night after discharge. CONCLUSIONS Homeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.
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Affiliation(s)
- S Ryan Greysen
- Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, Room U127A, Box 131, San Francisco, CA, 94143-0131, USA.
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Chwastiak L, Tsai J, Rosenheck R. Impact of health insurance status and a diagnosis of serious mental illness on whether chronically homeless individuals engage in primary care. Am J Public Health 2012; 102:e83-9. [PMID: 23078477 DOI: 10.2105/ajph.2012.301025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless. METHODS We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED. RESULTS The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use. CONCLUSIONS Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states' deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.
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Affiliation(s)
- Lydia Chwastiak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
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Marks SA, Moczygemba LR, Gatewood SB, Osborn RD, Wallace N, Lakhani S, Matzke GR, Goode JVR. The relationship between medication-related problems and behavioural health condition among patients served by a health care for the homeless centre. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2012. [DOI: 10.1111/j.1759-8893.2012.00091.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Abstract
Objectives
To evaluate the association between behavioural health conditions and the presence of a medication-related problem (MRP) and the association between the type of MRP and the presence of a dual diagnosis.
Methods
We used an existing database from a behavioural health clinic for homeless persons. Logistic regression was used to assess the relationship between the type of behavioural health condition and MRP presence, and whether the type of MRP varied with the presence of a dual diagnosis.
Key findings
A total of 426 patients were eligible. The majority were black (61%) and women (53%). Patients were 44.7 ± 10.2 years old, taking 3.4 ± 2.4 medications and had 2.3 ± 0.9 behavioural health conditions. The majority (53%) had a dual diagnosis, 44% had depression, 30% had a bipolar disorder, 26% had a personality disorder and 12% had an anxiety disorder. Bipolar [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.8–8.9] and anxiety disorders (OR 3.1, CI 1.0–9.2) and a dual diagnosis (OR 2.1, CI 1.2–3.8) were independently associated with the presence of an MRP. Patients with a dual diagnosis were more likely to have ineffective drug therapy (OR 1.7, CI 1.1–2.8) and less likely to have an adverse effect (OR 0.5, CI 0.3–0.9).
Conclusions
Patients with bipolar or anxiety disorders and/or a dual diagnosis may benefit from a pharmacist intervention to address MRPs. Pharmacists can make recommendations to improve the effectiveness of patients' medication therapy and help to resolve adverse effects.
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Affiliation(s)
| | - Leticia R. Moczygemba
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University
| | - Sharon B.S. Gatewood
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University
| | | | | | | | - Gary R. Matzke
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University
| | - Jean-Venable R. Goode
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University
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Moczygemba LR, Goode JVR, Gatewood SBS, Osborn RD, Alexander AJ, Kennedy AK, Stevens LP, Matzke GR. Integration of collaborative medication therapy management in a safety net patient-centered medical home. J Am Pharm Assoc (2003) 2011; 51:167-72. [PMID: 21382806 PMCID: PMC3280342 DOI: 10.1331/japha.2011.10191] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the integration of collaborative medication therapy management (CMTM) into a safety net patient-centered medical home (PCMH). SETTING Federally qualified Health Care for the Homeless clinic in Richmond, VA, from October 2008 to June 2010. PRACTICE DESCRIPTION A CMTM model was developed by pharmacists, physicians, nurse practitioners, and social workers and integrated with a PCMH. CMTM, as delivered, consisted of (1) medication assessment, (2) development of care plan, and (3) follow-up. PRACTICE INNOVATION CMTM is integrated with the medical and mental health clinics of PCMH in a safety net setting that serves homeless individuals. MAIN OUTCOME MEASURES Number of patients having a CMTM encounter, number and type of medication-related problems identified for a subset of patients in the mental health and medical clinics, pharmacist recommendations, and acceptance rate of pharmacist recommendations. RESULTS Since October 2008, 695 patients have had a CMTM encounter. An analysis of 209 patients in the mental health clinic indicated that 425 medication-related problems were identified (2.0/patient). Pharmacists made 452 recommendations to resolve problems, and 384 (85%) pharmacist recommendations were accepted by providers and/or patients. For 40 patients in the medical clinic, 205 medication-related problems were identified (5.1/patient). Pharmacists made 217 recommendations to resolve the problems, and 194 (89%) recommendations were accepted. CONCLUSION Integrating CMTM with a safety net PCMH was a valuable patient-centered strategy for addressing medication-related problems among homeless individuals. The high acceptance rate of pharmacist recommendations demonstrates the successful integration of pharmacist services.
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Gatewood SBS, Moczygemba LR, Alexander AJ, Osborn RD, Reynolds-Cane DL, Matzke GR, Goode JVR. Development and Implementation of an Academic-Community Partnership to Enhance Care among Homeless Persons. Innov Pharm 2011; 2:1-7. [PMID: 22259752 PMCID: PMC3258539 DOI: 10.24926/iip.v2i1.208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
An academic-community partnership between a Health Care for the Homeless (HCH) clinic and a school of pharmacy was created in 2005 to provide medication education and identify medication related problems. The urban community based HCH clinic in the Richmond, VA area provides primary health care to the homeless, uninsured and underinsured. The center also offers eye care, dental care, mental health and psychiatric care, substance abuse services, case management, laundry and shower facilities, and mail services at no charge to those in need. Pharmacist services are provided in the mental health and medical clinics. A satisfaction survey showed that the providers and staff (n = 13) in the clinic were very satisfied with the integration of pharmacist services. The quality and safety of medication use has improved as a result of the academic-community collaborative. Education and research initiatives have also resulted from the collaborative. This manuscript describes the implementation, outcomes and benefits of the partnership for both the HCH clinic and the school of pharmacy.
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Affiliation(s)
- Sharon B S Gatewood
- Department of Pharmacotherapy and Outcomes Sciences, School of Pharmacy, Virginia Commonwealth University
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Small LFF. Determinants of physician utilization, emergency room use, and hospitalizations among populations with multiple health vulnerabilities. Health (London) 2010; 15:491-516. [PMID: 21169208 DOI: 10.1177/1363459310383597] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Understanding the factors that influence differing types of health care utilization within vulnerable groups can serve as a basis for projecting future health care needs, forecasting future health care expenditures, and influencing social policy. In this article the Behavioral Model for Vulnerable Populations is used to evaluate discretionary (physician visits) and non-discretionary (emergency room visits, and hospitalizations) health utilization patterns of a sample of 1466 respondents with one or more vulnerable health classification. Reported vulnerabilities include: (1) persons with substance disorders; (2) homeless persons; (3) persons with mental health problems; (4) victims of violent crime; (5) persons diagnosed with HIV/AIDS; (6) and persons in receipt of public benefits. Hierarchical logistic regression is used on three nested models to model factors that influence physician visits, emergency room visits, and hospitalizations. Additionally, bivariate logistic regression analyses are completed using a vulnerability index to evaluate the impact of increased numbers of vulnerability on all three forms of health care utilization. Findings from this study suggest the Behavioral Model of Vulnerable Populations be employed in future research regarding health care utilization patterns among vulnerable populations. This article encourages further research investigating the cumulative effect of health vulnerabilities on the use of non-discretionary services so that this behavior could be better understood and appropriate social policies and behavioral interventions implemented.
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O'Toole TP, Buckel L, Bourgault C, Blumen J, Redihan SG, Jiang L, Friedmann P. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health 2010; 100:2493-9. [PMID: 20966377 DOI: 10.2105/ajph.2009.179416] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared a population-tailored approach to primary care for homeless veterans with a usual care approach. METHODS We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care. RESULTS Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01). CONCLUSIONS Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.
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Affiliation(s)
- Thomas P O'Toole
- Providence Veterans Affairs Medical Center for Systems, Outcomes, and Quality in Chronic Disease and Rehabilitation, Providence, RI 02908-4799, USA.
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Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless population. Public Health Rep 2010; 125:398-405. [PMID: 20433034 DOI: 10.1177/003335491012500308] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Homeless individuals frequently use emergency departments (EDs), but previous studies have investigated local rather than national ED utilization rates. This study sought to characterize homeless people who visited urban EDs across the U.S. METHODS We analyzed the ED subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED), a nationally representative probability survey of ED visits, using methods appropriate for complex survey samples to compare demographic and clinical characteristics of visits by homeless vs. non-homeless people for survey years 2005 and 2006. RESULTS Homeless individuals from all age groups made 550,000 ED visits annually (95% confidence interval [CI] 419,000, 682,000), or 72 visits per 100 homeless people in the U.S. per year. Homeless people were older than others who used EDs (mean age of homeless people = 44 years compared with 36 years for others). ED visits by homeless people were independently associated with male gender, Medicaid coverage and lack of insurance, and Western geographic region. Additionally, homeless ED visitors were more likely to have arrived by ambulance, to be seen by a resident or intern, and to be diagnosed with either a psychiatric or substance abuse problem. Compared with others, ED visits by homeless people were four times more likely to occur within three days of a prior ED evaluation, and more than twice as likely to occur within a week of hospitalization. CONCLUSIONS Homeless people who seek care in urban EDs come by ambulance, lack medical insurance, and have psychiatric and substance abuse diagnoses more often than non-homeless people. The high incidence of repeat ED visits and frequent hospital use identifies a pressing need for policy remedies.
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Affiliation(s)
- Bon S Ku
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Rising inability to obtain needed health care among homeless persons in Birmingham, Alabama (1995-2005). J Gen Intern Med 2009; 24:841-7. [PMID: 19415393 PMCID: PMC2695531 DOI: 10.1007/s11606-009-0990-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 03/07/2009] [Accepted: 03/18/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Homeless persons depend disproportionately on the health-care safety net for medical services. National reports identify financial strains to this safety net. Whether this has affected homeless persons is unknown. OBJECTIVES We quantified changes in the proportion of homeless persons reporting unmet need for health care in Birmingham, Alabama, comparing two periods, 1995 and 2005. We assessed whether a period effect was independent of characteristics of persons surveyed. DESIGN Analysis of two surveys conducted with identical methods among representative samples of homeless persons in 1995 (n = 161) and 2005 (n = 161). MEASUREMENTS Report of unmet need (inability to obtain care when needed) was the dependent variable. Two survey periods (1995 and 2005) were compared, with multivariable adjustment for sociodemographic and health characteristics. Reasons for unmet need were determined among the subset of persons reporting unmet need. RESULTS Unmet need for health care was more common in 2005 (54%) than in 1995 (32%) (p < 0.0001), especially for non-Blacks (64%) and females (65%). Adjusting for individual characteristics, a survey year of 2005 independently predicted unmet need (odds ratio 2.68, 95% CI 1.49-4.83). Among persons reporting unmet need (87 of 161 in 2005; 52 of 161 in 1995), financial barriers were more commonly cited in 2005 (67% of 87) than in 1995 (42% of 52) (p = 0.01). CONCLUSION A rise in unmet health-care needs was reported among Birmingham's homeless from 1995 to 2005. This period effect was independent of population characteristics and may implicate a local safety net inadequacy. Additional data are needed to determine if this represents a national trend.
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Pediatric Emergency Department Overcrowding: Electronic Medical Record for Identification of Frequent, Lower Acuity Visitors. Can We Effectively Identify Patients for Enhanced Resource Utilization? J Emerg Med 2009; 36:311-6. [DOI: 10.1016/j.jemermed.2007.10.090] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 10/10/2007] [Accepted: 10/23/2007] [Indexed: 11/19/2022]
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Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department. Ann Emerg Med 2008; 53:598-602. [PMID: 18838193 DOI: 10.1016/j.annemergmed.2008.07.046] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/16/2008] [Accepted: 07/23/2008] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations. METHODS In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument. RESULTS One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED. CONCLUSION Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.
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Savage CL, Lindsell CJ, Gillespie GL, Lee RJ, Corbin A. Improving health status of homeless patients at a nurse-managed clinic in the Midwest USA. HEALTH & SOCIAL CARE IN THE COMMUNITY 2008; 16:469-475. [PMID: 18266719 DOI: 10.1111/j.1365-2524.2007.00758.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Homeless adults have a higher rate of morbidity and mortality than their housed counterparts. Improving the health of homeless adults is a complex problem because of the overlay of individual risk factors, social issues and lack of economic resources. Due to the increased morbidity and mortality rate in homeless adults, it is imperative to develop interventions with demonstrated efficacy that result in improved health outcomes. The purpose of this pre-post pilot study was to compare pre- and post-test scores on specific health outcomes in a group of homeless adults receiving a nurse intervention when utilising a nurse-managed clinic located in the urban core of a Midwestern city in the USA. Between September of 2004 and January 2006, 43 homeless adults completed a health survey at baseline and 2 months later that included measures of health-related quality of life (HRQOL), substance use and health resource use. There was a significant improvement on the post-test scores including substance use, perceived quality and availability of health care, and on two domains of HRQOL: mental health and vitality. This study provides evidence that a nursing intervention can result in improved health outcomes for adult homeless persons.
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Savage CL, Lindsell CJ, Gillespie GL, Dempsey A, Lee RJ, Corbin A. Health care needs of homeless adults at a nurse-managed clinic. J Community Health Nurs 2007; 23:225-34. [PMID: 17064232 DOI: 10.1207/s15327655jchn2304_3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Up to 55% of the homeless population report health problems. They often use the emergency department (ED) to obtain care when the health needs are not urgent. Nurse-managed clinics have the potential to reduce nonurgent ED use and improve the health of the homeless. The purpose of this study was to establish baseline health data on homeless persons prior to attending a nurse-managed clinic.(1) This study was a cross-sectional, retrospective health survey of homeless clients at a nurse-managed clinic. A total of 110 participants completed a baseline health survey. Of these, 61% reported that prior to coming to the clinic, they used the ED as a source of health care. The most frequent medical diagnoses reported were substance use disorders, depression, back pain, hypertension, and asthma. Providing care for chronic conditions at a nurse-managed clinic has the potential to improve health and reduce use of the ED.
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Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health 2006; 96:1278-81. [PMID: 16735635 PMCID: PMC1483848 DOI: 10.2105/ajph.2005.067850] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Homeless individuals experience high rates of physical and mental illness, increased mortality, and frequent hospitalizations. Respite care provides homeless individuals with housing and services allowing more complete recovery from illnesses and stabilization of chronic conditions. METHODS We investigated respite care's impact on 225 hospitalized homeless adults consecutively referred from an urban public hospital during a 26-month period. The cohort was separated into 2 groups: (1) patients referred and accepted into the respite center and (2) patients referred but denied admission because beds were unavailable. All patients met the center's predefined eligibility criteria. Main outcome measures were inpatient days, emergency department visits, and outpatient clinic visits. RESULTS The 2 groups had similar demographic characteristics, admitting diagnoses, and patterns of medical care use at baseline. During 12 months of follow-up, the respite care group required fewer hospital days than the usual care group (3.7 vs 8.3 days; P=.002), with no differences in emergency department or outpatient clinic visits. Individuals with HIV/AIDS experienced the greatest reduction in hospital days. CONCLUSIONS Respite care after hospital discharge reduces homeless patients' future hospitalizations.
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Affiliation(s)
- David Buchanan
- Department of Medicine at Stroger Hospital of Cook County, Chicago, Illinois, USA.
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