Among adults experiencing homelessness in Ontario, Canada, those with a mental illness are more likely to use emergency, inpatient, and physician services, according to a new report.
In general, homelessness is associated with higher healthcare needs, hospitalizations, and primary care appointments, compared with low-income control groups, the study authors wrote. At the same time, healthcare use isn’t uniform among people experiencing homelessness.
Kathryn Wiens PhD
“There is a subgroup of people experiencing homelessness who use acute healthcare services more frequently,” study author Kathryn Wiens, PhD, a graduate of the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News.
“Knowing this, we can identify risk factors and health behaviors that are associated with higher use,” she said. “We can work to develop effective interventions within healthcare to meet the individual needs of people experiencing homelessness.”
The study was published online Oct. 26 in Health Services Insights.
Two Homeless Cohorts
The investigators linked Ontario administrative healthcare records with survey data from the At Home/Chez Soi study and the Health and Housing in Transition study to identify factors associated with hospital admissions, emergency department visits, and physician visits.
The At Home/Chez Soi study was a randomized controlled trial of Housing First, a supportive housing intervention for adults experiencing homelessness with a diagnosed mental illness. Conducted from 2009 to 2013 in several Canadian cities, the study stratified participants by their level of mental health needs. The current investigators included 525 participants from the Toronto area in this group as the cohort experiencing a mental illness.
The Health and Housing in Transition study was a long-term study of adults with a history of homelessness, conducted between 2009 and 2014 in Toronto, Ottawa, and Vancouver, Canada. The participants were either homeless or had experienced homelessness in the past year. Wiens and colleagues included 655 participants from the Toronto and Ottawa areas in this group as the general cohort of people experiencing homelessness.
On average, the cohort with a mental illness tended to be younger, more likely to report a regular source of healthcare, perceive a barrier to care, and report not having enough food to eat. They were also more likely to reside in Toronto, identify as Black or another racialized group, have a psychotic disorder, and have accessed acute mental healthcare in the past year.
The cohort with a mental illness had higher rates of inpatient (27% vs 14%), emergency (63% vs 53%), and physician (90% vs 76%) service use, compared with the general cohort. About 10% of those with a mental illness had two or more hospitalizations, compared with 5% of those in the general cohort of people experiencing homelessness.
In addition, about 21% of participants with a mental illness had five or more emergency department visits, compared with 13% in the general group. About 67% participants with a mental illness had five or more physician visits, compared with 46% in the general group.
In both groups, Black participants were 40% less likely to be admitted to a nonpsychiatric hospital unit, and they had much lower rates of emergency department visits and physician visits than White participants did. People from other racialized groups were 20% less likely to have psychiatric hospitalizations and 25% less likely to have physician visits.
Dr Stephen Hwang
“There are many reasons why people from racialized groups may not access healthcare services,” senior study author Stephen Hwang, MD, professor of medicine at the University of Toronto, Toronto, Ontario, Canada, and director of the MAP Centre for Urban Health Solutions at St. Michael’s Hospital, told Medscape Medical News.
“While the hospital can be a valuable place to identify and support people experiencing homelessness, we must be careful not to prioritize housing and support interventions based on prior high use of healthcare services, as this can perpetuate systemic racism,” he said.
Certain types of predisposing, enabling, and need factors were associated with multiple types of healthcare services. Participants in the general homeless cohort who had a regular source of care were nearly three times more likely to have a nonpsychiatric hospitalization than those without a regular source of care. In both cohorts, those who had a regular source of care also had higher rates of emergency department visits and physician visits.
In addition, those who had used mental health acute services in the past year had a five-times higher risk of psychiatric hospitalization. Those who had used non-mental health acute services had a four-times higher rate of emergency department visits.
Those with poorer health and more chronic conditions also had more healthcare use. People with three or more chronic conditions or poor health had a nearly three-times higher risk of nonpsychiatric hospitalization and up to two-times higher rate of emergency department and physician visits.
Healthcare-driven strategies to address homelessness should consider the distribution of healthcare use among the homeless and individual characteristics and behaviors that influence healthcare use, the authors wrote. Importantly, they need to include a trauma-informed and layered approach to care to reduce the risk of retraumatization.
John Graham PhD
Commenting on the study for Medscape, John Graham, PhD, professor of social work at the University of British Columbia, Vancouver, British Columbia, Canada, and principal investigator of the Kelowna Homelessness Research Collaborative, said, “We need to better understand how to tailor interventions to the particular experiences and backgrounds of service users.”
Graham, who wasn’t involved with this study, researches homelessness prevention in British Columbia, Canada, including particular service protocols for people with specific healthcare needs.
“Strategies to assist these individuals need to be anchored to health statuses and other aspects of their lives,” he said. “Only then can resource systems provide the necessary supports that meet the genuine needs of service users. But even then, there are massive problems of system access.”
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The authors declared no conflicts of interest, and Graham reported no relevant disclosures.
Health Serv Insights. Published Oct. 26, 2022. Full text.
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.
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