Hospitalizations Are on the Rise Among Homeless Individuals

An estimated 553,000 individuals in the United States are homeless on any given night, yet few data are available to give insight into the patterns of acute illness in this particularly vulnerable population. Now, a retrospective cohort study by investigators from Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center (BIDMC) examined hospitalizations among homeless individuals in 3 highly populated and diverse US states—Florida, California, and Massachusetts—and found that hospitalizations among homeless individuals are rising.

The study, published in Medical Care, compared 185,292 hospitalizations for homeless individuals with 32,322,569 hospitalizations for nonhomeless individuals from 2007 to 2013 in the 3 states assessed. The researchers then calculated the annual hospitalization rates for homeless individuals and compared the causes of hospitalization with the nonhomeless cohort of patients. They used logistic and linear regression models to estimate risk-standardized outcomes among these patient groups.

The researchers found that homeless patients were, on average, 46 years old, often male (76.1%), white (62%), and either uninsured (41.9%) or insured by Medicaid (31.7%). Among all 3 states studied, hospitalizations among homeless individuals rose during the period studied. In Massachusetts, hospitalizations rose from 294 to 420 per 1000 homeless residents. In Florida, that number increased from 161 to 240, and in California, from 133 to 164.

"The homeless population is aging, and the rate of hospitalizations for homeless individuals is increasing," the study’s lead author, Rishi Wadhera, MD, a cardiology fellow at the Brigham and Women’s Hospital and a health policy researcher at BIDMC, said in a statement. "Although there has been a recent push to establish better policy and public health measures to improve the health of homeless adults, few studies have examined the patterns and causes of hospitalizations in this population. We found that hospitalizations among homeless adults tend to be for a very different set of conditions than non-homeless adults, even after accounting for differences in demographics."

Specifically, Wadhera and colleagues found that homeless individuals were more frequently hospitalized for mental illness and substance use disorders than were nonhomeless individuals.

One possible reason for the increased hospitalization of homeless individuals, Wadhera and colleagues said, is the expansion of Medicaid eligibility, which has increased the rates of insurance in this population. Improved access to care may have led to greater use of hospital services.

However, the researchers also noted that there may be a more troubling reason for the trend: “The opioid epidemic has disproportionately impacted the homeless population, and a repercussion of this may be an increase in acute hospitalizations,” said Wadhera, adding that it is also possible that a rise in hospitalizations may reflect inadequate outpatient care for this underserved population.

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

Reference

Wadhera RK, Choi E, Shen C, Yeh RW, Joynt Maddox KE. Trends, causes and outcomes of hospitalizations for homeless individuals: a retrospective cohort study. Med Care. 2019;57(1): 21-27. doi: 10.1097/MLR.0000000000001015.