A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services

We found that the Permanent Supportive Housing program intervention was able to house 86 percent of chronically homeless adults randomized to the treatment group based on their high use of multiple systems who were randomized to the treatment group. On average, it took 2.5 months for participants randomized to housing to become housed and 70 percent moved at least once, demonstrating that PSH can be successful with high‐risk participants but requires time and flexibility.By using a randomized controlled trial design, we found that those randomized to housing (versus usual care) had lower use of psychiatric emergency departments and shelters, but did not have large reductions in service use described in previous uncontrolled studies.This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grant MRP-19-600774

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

ObjectiveOut-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Data sources and study settingEnrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.Study designWe analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).Data extraction methodsWe extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Principal findingsOf 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.ConclusionsThere are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity

How Hospital Discharge Data Can Inform State Homelessness Policy

California emergency departments (EDs) treated about 143,000 people experiencing homelessness in 2019, according to hospital discharge records. Almost half of homeless patients visited the ED four or more times in the year.Medi-Cal covered 70 percent of ED visits by homeless patients, underscoring the importance of the CalAIM program, which provides added Medi-Cal benefits, such as housing supports and case management.Linking discharge data with homeless assistance program data can offer insights into how people engage with EDs and homeless services across the state, and throughout the year, as well as help evaluate programs and public investments.This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants MRP-19-600774 and M21PR327

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

ObjectiveOut-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Data sources and study settingEnrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.Study designWe analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).Data extraction methodsWe extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Principal findingsOf 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.ConclusionsThere are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review.

Study objectivePrevious reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events.MethodsWe identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate- to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations.ResultsWe evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations.ConclusionHigh-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation

Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study.

BackgroundThe median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults.ObjectiveThis study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years.MethodsWe recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies.ResultsOf the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72).ConclusionsOlder homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes

Understanding the 100 highest users of health and social services in San Francisco

This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants M21PR3278

Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study.

ObjectiveThe 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.MethodsWe 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.ResultsIn 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.ConclusionsA 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

Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic.

ImportanceThere has been recent media attention on the risk of excess mortality among homeless individuals during the COVID-19 pandemic, yet data on these deaths are limited.ObjectivesTo quantify and describe deaths among people experiencing homelessness in San Francisco during the COVID-19 pandemic and to compare the characteristics of these deaths with those in prior years.Design, setting, and participantsA cross-sectional study tracking mortality among people experiencing homelessness from 2016 to 2021 in San Francisco, California. All deceased individuals who were homeless in San Francisco at the time of death and whose deaths were processed by the San Francisco Office of the Chief Medical Examiner were included. Data analysis was performed from August to October 2021.ExposureHomelessness, based on homeless living status in an administrative database.Main outcomes and measuresDescriptive statistics were used to understand annual trends in demographic characteristics, cause and manner of death (based on autopsy), substances present in toxicology reports, geographic distribution of deaths, and use of health and social services prior to death. Total estimated numbers of people experiencing homelessness in San Francisco were assessed through semiannual point-in-time counts. The 2021 point-in-time count was postponed owing to the COVID-19 pandemic.ResultsIn San Francisco, there were 331 deaths among people experiencing homelessness in the first year of the COVID-19 pandemic (from March 17, 2020, to March 16, 2021). This number was more than double any number in previous years (eg, 128 deaths in 2016, 128 deaths in 2017, 135 deaths in 2018, and 147 deaths in 2019). Most individuals who died were male (268 of 331 [81%]). Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury. COVID-19 was not listed as the primary cause of any deaths. The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic). Fewer decedents had contacts with health services in the year prior to their death during the pandemic than in prior years (13% used substance use disorder services compared with 20% in 2019).Conclusions and relevanceIn this cross-sectional study, the number of deaths among people experiencing homelessness in San Francisco increased markedly during the first year of the COVID-19 pandemic. These findings may guide future interventions to reduce mortality among individuals experiencing homelessness