Non-homeless Patients Research Articles

Health Care Utilization of Homeless Minors With Diabetes in New York State From 2009 to 2014.

This study aims to describe differences in health care utilization between homeless and nonhomeless minors with diabetes. Data from the Healthcare Cost and Utilization Project's Statewide Inpatient Database from New York for years 2009-2014 were examined to identify pediatric patients <18 years old with diabetes. Outcomes of interest included hospitalization rate, in-hospital mortality, admission through the emergency department (ED), diabetic ketoacidosis (DKA), hospitalization cost, and length of stay (LOS). Other variables of interest included age-group, race/ethnicity, insurance type, and year. Multivariate logistic regression models were used for in-hospital mortality, admission through ED, and DKA. Log-transformed linear regression models were used for hospitalization cost, and negative binomial regression models were used for LOS. A total of 643 homeless and 10,559 nonhomeless patients were identified. The hospitalization rate was higher among homeless minors, with 3.64 per 1,000 homeless population compared with 0.38 per 1,000 in the nonhomeless population. A statistically significant higher readmission rate was detected among homeless minors (20.4% among homeless and 14.1% among nonhomeless, P < 0.01). Lower rates of DKA (odds ratio 0.75, P = 0.02), lower hospitalization costs (point estimate 0.88, P < 0.01), and longer LOS (incidence rate ratio 1.20, P < 0.01) were detected among homeless minors compared with nonhomeless minors. This study found that among minors with diabetes, those who are homeless experience a higher hospitalization rate than the nonhomeless. Housing instability, among other environmental factors, may be targeted for intervention to improve health outcomes.

MP04: Predicting future ED needs – population trends may not be enough!

Introduction: As the population of Canadian cities grows, public policy planners frequently base predictions of future demand on population trends. We aimed to discover the relationship between demographically defined ED visit rate (EDVR) trends in an academic ED with corresponding population trends in the catchment area. Methods: We used administrative data to conduct a retrospective cohort time series to analyze per capita EDVR trends based on CTAS, age, gender and housing status for the period 2006-2015. These were adjusted for population growth using age-gender standardized rates from 2011 census data. All EDVR and Standardized estimates were extrapolated for 100,000 population. Results: There were 646 731 visits during the study period, increasing by 25.6% from 56 757 in 2006 to 71 289 in 2015, with an annual incremental linear trend of 1893/year (CI:1593-2192). The highest CTAS2 EDVR increase, 521/year, (95%CI: 433-608) was by non-homeless patients older than 49. CTAS2 visits and the rate in all non-homeless patients increased by 335/year, (95% CI 280-391), while homeless patients less than 30 showed the highest CTAS2 EDVR annual rate incremease (1183/year, CI:1448-2218). From 2008-2015, the annual linear per capita CTAS5 EDVR declined by 121/year (CI:79-163). The population of adults in Halifax increased by1.2%/yr with a linear trend of 4149/year (CI:4012-4287). The highest linear increasing trend was for those older than 49 (2604/year CI:2494-2714), followed by 30-50-year old group (1223/year, CI:1138-1309) with the lowest trend for those aged less than 30 (322/year,CI:170-473). Standardized and non-standardized rate decline (CTAS5) and incline (CTAS2) were statistically similar and were not influenced by population changes. The population older than 49 increased by 38% over the 10 year period, whereas the CTAS2 visit change increased by 250%. If the CTAS2 EDVR trend continues, this rate in 2027 will double that of 2015, even if the population in the catchment area remains stable. Conclusion: EDVR trends show an increase in CTAS2 visits driven chiefly by older patients. This trend exceeds the trend suggested by Canadian Foundation for Healthcare Improvement and is significantly more than predicted by population demographic changes. Healthcare administrators will need to bear these disparities in mind as they prepare for future ED capabilities.

P084: Hard-to-reach populations and administrative health data: a serial cross-sectional study and application of data to improve interventions for people experiencing homelessness

Introduction: Administrative data can aid in study and intervention design, incorporating hard-to-reach individuals who may otherwise be poorly represented. We aim to use administrative health data to examine emergency department visits by people experiencing homelessness and explore the application of this data for planning interventions. Methods: We conducted a serial cross-sectional study examining emergency department use by people experiencing homelessness and non-homeless individuals in the Niagara region of Ontario, Canada. The study period included administrative health data from April 1st, 2010 to March 31st, 2018. Outcomes included number of visits, number of unique patients; group proportions of Canadian Triage and Acuity Scale (CTAS) scores; time spent in emergency; and time to see an MD. Descriptive statistics were generated, and t-tests were performed for point estimates and a Mann-Whitney U test for distributional measures. Results: Our data included 1,486,699 emergency department visits. The number of unique people experiencing homelessness ranged from 91 in 2010 to 344 in 2017, trending higher over the study period compared to non-homeless patients. The rate of visits increased from 1.7 to 2.8 per person. People experiencing homelessness tend to present later in the day and with higher overall acuity as compared to the general population. Time in emergency department and time to see an MD were greater among people experiencing homelessness. Conclusion: Administrative health data allows researchers to enhance interventions and models of care to improve services for vulnerable populations. Given the challenging fiscal realities of research, our study provides insights to more effectively target interventions for vulnerable populations.

Cardiovascular Outcomes and Rehospitalization Rates in Homeless Patients Admitted With Acute Myocardial Infarction

ObjectiveTo study the in-hospital outcomes and 30-day readmission data in homeless patients admitted with acute myocardial infarction (AMI). MethodsAdult patients (>18 years of age) who were admitted with AMI between January 1, 2015, and December 31, 2016, were identified in the National Readmission Database. Patients were classified into homeless or non-homeless. Baseline characteristics, rates of invasive assessment and revascularization, mortality, 30-day readmission rates, and reasons for readmission were compared between the 2 cohorts. ResultsA total of 3938 of 1,100,241 (0.4%) index hospitalizations for AMI involved homeless patients. Compared with non-homeless patients, homeless patients were younger (mean age, 57±10 years vs 68±14 years; P<.001) and had a lower prevalence of atherosclerotic risk factors (hypertension, hyperlipidemia, and diabetes) but a higher prevalence of anxiety, depression, and substance abuse. Homeless patients were less likely to undergo coronary angiography (38.1% vs 54%; P<.001), percutaneous coronary intervention (24.1% vs 38.7%; P<.001), or coronary artery bypass grafting (4.9% vs 6.7%; P<.001). Among patients who underwent percutaneous coronary intervention, bare-metal stent use was higher in homeless patients (34.6% vs 12.1%; P<.001). After propensity score matching, homeless patients had similar mortality but higher rates of acute kidney injury, discharge to an intermediate care facility or against medical advice, and longer hospitalizations. Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%; P<.001). Homeless patients had more readmissions for psychiatric causes (18.0% vs 2.0%; P<.001). ConclusionConsiderable differences in cardiovascular risk profile, in-hospital care, and rehospitalization rates were observed in the homeless compared with non-homeless cohort with AMI. Measures to remove the health care barriers and disparities are needed.

“I WILL STAY AT MCDONALD'S FOR THE NIGHT. IT'S MY RIGHT TO BE HOMELESS.”; CHALLENGES IN TREATING AN ELDERLY HOMELESS MALE WITH BIPOLAR DISORDER AND MILD INTELLECTUAL DISABILITY AND MULTIPLE MEDICAL ISSUES

Introduction Frequent emergency department (ED) users make up nearly 30% of ED visits nationwide. Although there is no established definition of frequent ED utilization, the following classification was most commonly employed in recent literature: frequent users 4-9?visits/?year, super-users ≥ 10?visits/?year. Homelessness is strongly associated with frequent use of the emergency department services. According to the US department of Housing and Urban Development, the elderly homeless population has increased from 2.9 percent to 4.7 percent over the past 12?years. In addition to an increased risk of recidivism, homelessness is also associated with poor socioeconomic status, psychosocial issues, limited resources, and high incidences of mental health and substance abuse problems. However little research has been done towards identifying and characterizing subgroups within this population. Further classification of this vulnerable population might lead to the development of targeted interventions varying in intensity and composition with the goal of decreasing rates of recidivism. The objective of this case report is to discuss the challenges behind managing a homeless geriatric patient with complex comorbid medical and psychiatric conditions who qualifies as a super-utilizer with greater than 230 ED visits over 4?years who despite engagement is rejecting help and prefers to be homeless. This case also highlights the importance to continuously engage the patient and realizing that acceptance of “help” may not be instantaneous but requires a great deal of patience and trust acquisition. Methods This specific case was reviewed and compared to relevant literature for further discussion. Results Case Report Information: 62 year old Caucasian man, divorced and homeless, with a previous psychiatric history of Schizoaffective Disorder and mild Intellectual Disability and past medical history of hypertension, hyperlipidemia, coronary artery disease s/p stent placement, atrial fibrillation s/p ablation, AICD placement with pacemaker,heart failure, multiple strokes, and COPD presented to the emergency room under police custody after breaking a bus window with his cane and attempting to assault police officers. Review of records indicated approximately 40 inpatient medical admissions, the majority of which were exacerbations of existing chronic medical conditions due to non compliance and 4 psychiatric admissions over 4?years. On initial evaluation, the patient appeared disorganized and irritable with pressured and illogical speech, elevated mood, and paranoia associated with persecutory ideation. He displayed poor insight and judgement but consented to treatment with all prescribed medications and medical consultations. The patient began to improve with a regimen of Aripiprazole and Sodium Valproate over the course of his hospitalization. He became less disorganized and paranoid with speech that was more comprehensible. He was evaluated by the medical and cardiology consult service and recommended cardiology follow up and his pacemaker was interrogated ??? while on the unit. Pt was assisted in contacting his family in Mississippi from whom he was estranged. He was offered placement in supportive housing and case management services. He refused all shelter and housing services stating “I am a free man. I'm at the Mcdonald's nearby and I know the manager who allows me to sit there at night. I prefer to stay on the streets”. He displayed sufficient capacity to refuse offered resources. Although he agreed to follow up with both psychiatric and medical care once discharged, he did not show up for his scheduled appointments. Conclusions Frequent ED users are the focus of much research given the cost burden on healthcare systems. Moulin et al. analyzed the relationship between mental illness and frequent ED visits and found a strong association between homelessness and patients with Medicaid coverage with higher ED visit rates. homeless patients had higher rates of ED visits and hospitalizations and have higher morbidity and mortality when compared to non-homeless patients. Homeless patients with co-occurring medical problems have difficulty in keeping up with follow up and having adequate primary care follow up. Addressing barriers to outpatient care and providing supportive housing were among the most successful interventions found to positively improve healthcare utilization and expenditures. Other research corroborates intensive case management as the most successful intervention for recidivism prevention. Further research should focus on the need for collaborative care models targeting the complexities associated with geriatric psychiatric patients with co-occurring medical conditions as this could lead to improved care for this vulnerable patient population. It is important to analyze cases such as these to identify homelessness risk factors and associated characteristics that might indicate trends for the development of targeted prevention and early intervention strategies towards recidivism reduction and homelessness prevention. This research was funded by: Not applicable

Homeless patients tend to have greater psychiatric needs when presenting to the emergency department,

IntroductionHomeless patients tend to visit Emergency Departments (EDs) more frequently than the non-homeless population. The goal of this study was to assess differences in chief complaint, medical conditions, and disposition between homeless patients compared to non-homeless patients presenting to an urban ED. MethodsThis was a retrospective cohort of homeless patients ages ≥18 years compared to non-homeless controls from January 1, 2017 to December 31, 2017. Exclusion criteria were as follows: direct admission to hospital floor, repeat visits, or leaving without being seen. The primary endpoint of this study was to assess differences in chief complaint of homeless versus non-homeless patients upon presentation to the ED. Our secondary endpoints included differences in ED utilization between the two groups, in terms of length of stay, ambulance use, diagnosis, and disposition. ResultsHomeless patients were more likely present to the ED for a psychiatric evaluation (homeless group 34% vs. non-homeless group 4%, p < 0.01) and have a history of a psychiatric diagnosis (56% vs. 10%, p < 0.01) compared to non-homeless controls. Homeless patients also tended to require more ambulance transport (46% vs. 16%, p < 0.01). More homeless patients were transferred to a psychiatric facility (40% vs. 1%, p < 0.01), while the majority of non-homeless patients were discharged home (50% vs. 93%, p < 0.01). ConclusionThis study found that homeless patients had a significantly higher association with psychiatric diagnoses and greater ED utilization than non-homeless. This suggests the importance of increased access to consistent psychiatric care and follow up within the homeless population.

Findings of a national dataset analysis on the visits of homeless patients to US emergency departments during 2005-2015

ObjectivesTo our knowledge, there has been limited description of emergency department (ED) visits involving homeless patients over the last decade. Our study aims to analyze US national survey data to elucidate the differences between homeless and non-homeless patients’ ED visits in terms of patient demographics, resource utilization, and diagnoses received. Study designThis was a retrospective study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 until 2015. MethodsPatient visits were classified as homeless or non-homeless based on survey data; appropriate statistical analyses were subsequently performed to compare these groups in terms of patient demographics, geography, payment method, resource utilization/diagnostic service use, as well as both psychiatric and non-psychiatric diagnoses received in the ED. ResultsNHAMCS data from 2005 to 2015 were aggregated. In total, 303,326 patient visits were included, which represent an estimated 1.30 billion ED visits over this period. Of these, 2750 encounters were by homeless people, representing 8,781,925 ED visits. Compared with non-homeless visits, homeless patients were disproportionately male, black, non-Hispanic, and seen in large metropolitan areas or the Western/Southern US. Homeless visits were more likely to be related to an injury (47.5% vs. 33.8%), related to an assault (4.2% vs. 1.3%), or self-inflicted (4.8% vs 0.84%). Homeless patients were also more likely to have been seen in the same ED within 72 h (7.3% vs. 3.9%) compared with non-homeless patients (3.9%, 95% confidence interval [CI]: 3.5–4.4) and were seen an average of 5.7 times (95% CI: 4.7–6.8) in the same ED over the preceding 12 months, with non-homeless patients seen an average of 3.2 times (95% CI: 3.1–3.4). Homeless patients were more likely to be admitted to the hospital (14.9% vs. 11.2%) and, when admitted, spent an average of 6.3 days in the hospital (95% CI: 5.6–7.1) compared with non-homeless patients at 5.2 (95% CI: 5.1–5.3). In total, 28.4% of homeless patients received a psychiatric diagnosis (95% CI: 25.8–31.2) compared with 5.4% for non-homeless patients (95% CI: 5.2–5.7, P < 0.001). In reference to non-homeless visits, homeless visits showed increased odds of alcohol-related diagnoses (odds ratio [OR]: 17.3, 95% CI: 10.1–29.8, P < 0.001) and substance abuse diagnoses (OR: 8.4, 95% CI: 7.2–9.8, P < 0.001). Homeless visits also exhibited greatly increased odds of diagnosis of schizophrenia (OR: 16.6, 95% CI: 12.6–22.5, P < 0.001) and personality disorders (OR: 15.4, 95% CI: 6.4–36.9, P < 0.001). ConclusionsLess than one in 100 US ED visits in 2005–2015 were made by homeless patients. Compared with the non-homeless, homeless patients had greatly increased rates of ED care for alcohol-related, substance abuse–related, and mental health–related problems, particularly schizophrenia and personality disorders. Homeless patients were also more likely to be seen in the ED within the past 72 h or the past 12 months. Homeless patients were more likely to be admitted to the hospital and, when admitted, exhibited longer stay times.

Asthma Hospitalizations Among Homeless Children in New York State.

Asthma is widely prevalent among US children, particularly in homeless children, who often lack proper medication storage or the ability to avoid environmental triggers. In this study, we assess asthma-attributed health care use among homeless youth. We hypothesize that asthma hospitalization rates, symptom severity, and admission through the emergency department (ED) will be higher among homeless youth compared with nonhomeless youth. This secondary data analysis identified homeless and nonhomeless pediatric patients (<18 years old) with a primary diagnosis of asthma from New York statewide inpatient databases between 2009 and 2014. Hospitalization rate, readmission rate, admission through the ED, ventilation use, ICU admittance, hospitalization cost, and length of stay were measured. We identified 71 837 asthma hospitalizations, yielding 73.8 and 2.3 hospitalizations per 1000 homeless and nonhomeless children, respectively. Hospitalization rates varied by nonhomeless income quartile, with low-income children experiencing higher rates (5.4) of hospitalization. Readmissions accounted for 16.0% of homeless and 12.5% of nonhomeless hospitalizations. Compared with nonhomeless patients, homeless patients were more likely to be admitted from the ED (odds ratio 1.96; 95% confidence interval: 1.82-2.12; P < .01), and among patients >5 years old, homeless patients were more likely to receive ventilation (odds ratio 1.45; 95% confidence interval: 1.01-2.09; P = .04). No significant differences were observed in ICU admittance, cost, or length of stay. Homeless youth experience an asthma hospitalization rate 31 times higher than nonhomeless youth, with higher rates of readmission. Homeless youth live under uniquely challenging circumstances. Tailored asthma control strategies and educational intervention could greatly reduce hospitalizations.

1236-P: Hospitalizations Rates among Homeless Children with Diabetes Mellitus in New York

Background: Diabetes mellitus (DM) is increasing in prevalence among U.S. children. Disparity across race and socioeconomic status for DM incidence as well as DM outcomes have been reported. Homeless youth live under unique circumstances that may lead to challenges in self-care. We hypothesized that homelessness may be associated with difficulties in blood glucose management, and therefore would lead to increased healthcare utilization. The aim of this study was to assess healthcare utilization related to DM among homeless youth. Methods: This secondary data analysis identified homeless and non-homeless pediatric patients (&amp;lt;18 years) with a primary diagnosis of DM from the New York statewide inpatient database between 2009 and 2014. Hospitalization rates, readmission rates, hospitalizations with ketoacidosis, admissions through the emergency department (ED), and hospitalization costs and lengths of stay (LOS) were used as outcomes. Results: We identified 11,202 DM-related hospitalizations, yielding 4.26 and 0.41 hospitalizations per 1,000 homeless and non-homeless children, respectively. Readmissions accounted for 21.0% of homeless and 14.6% of non-homeless hospitalizations (p&amp;lt; .01). Compared with non-homeless patients, homeless patients were more likely to be admitted from ED: Odds Ratio (OR) 1.53, p&amp;lt;.01. Stratified analyses by DM type revealed that homeless patients with DM1 had longer LOS than non-homeless patients: Incidence Rate Ratio (IRR) 1.23, p&amp;lt;.01, whereas a difference in LOS was not detected among patients with DM2. No other outcomes were associated with homelessness. Conclusions: Homeless youth experience 10.4 times higher DM hospitalization rates than non-homeless youth, with higher rates of readmission. Healthcare utilization was especially high for homeless youth with DM1. Further studies are needed to examine the factors contributing to increased healthcare utilization in order to develop tailored management strategies for homeless youth with diabetes. Disclosure R. Sakai-Bizmark: None. J.K. Yee: None.

Comparison of clinical characteristics and outcomes between homeless and non-homeless patients admitted to intensive care units: An observational propensity-matched cohort study in Korea

PurposeTo compare clinical characteristics and outcomes between critically ill homeless and non-homeless patients admitted to the intensive care unit (ICU) in a Korea. Materials and methodsWe retrospectively analyzed the medical charts of homeless and non-homeless patients admitted to ICU at Seoul Boramae Medical Center between January 2012 and December 2017. Patients were selected using 1: 2 propensity score matching including age, sex, and type of ICU and multivariate analyses were performed to determine risk factors for hospital and ICU mortality. Results56 homeless and 112 non-homeless matched patients were analyzed. The homeless patients were younger, included more men, and exhibited significantly higher readmission and ER admission rates. Although hospital and ICU mortality rates were similar between two groups, the homeless patients were significantly less likely to have family or substitute decision-makers and generally died after cardiopulmonary resuscitation. Adjusted multivariate analysis showed that homelessness was not an independent predictor of ICU or hospital mortality. The length of ICU stay was comparable between groups. ConclusionsIn Korea, ICU-admitted homeless patients are well managed without differences in terms of organ support quality and exhibit the same prognosis as non-homeless patients. However, the quality of end-of-life care for homeless patients remains poor.

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

BackgroundWe aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.MethodsThis is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients’ general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.ResultsStudy enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).ConclusionsThough ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

An analysis of homeless patients in the United States requiring ICU admission

PurposeTo assess how homelessness impacts mortality and length of stay (LOS) among select the intensive care unit (ICU) patients. MethodsWe used ICD-9 code V60.0 to identify homeless patients using the Premier Perspective Database from January 2010 to June 2011. We identified three subpopulations who received critical care services using ICD-9 and Medicare Severity Diagnosis Related Groups (MS-DRG) codes: patients with a diagnosis of sepsis who were treated with antibiotics by Day 2, patients with an alcohol or drug related MS-DRG, and patients with a diabetes related MS-DRG. We used multivariable logistic regression to predict mortality and multivariable generalized estimating equations to predict hospital and ICU LOS. Results781,540 hospitalizations met inclusion criteria; 2278 (0.3%) were homeless. We found homelessness had no significant adjusted association with mortality among sepsis patients, but was associated with substantially longer hospital LOS: (3.7 days longer; 95% CI (1.7, 5.7, p < .001). LOS did not differ in the Diabetes or Alcohol and Drug related DRG groups. ConclusionsCritically ill homeless patients with sepsis had longer hospital LOS but similar ICU LOS and mortality risk compared to non-homeless patients. Homelessness was not associated with increased LOS in the diabetes or alcohol and drug related groups.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization

ObjectiveHomelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness. MethodsWe conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized. ResultsOver the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years. ConclusionsCompared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.

Substance use and homelessness among emergency department patients

BackgroundHomelessness and substance use often coexist, resulting in high morbidity. Emergency department (ED) patients have disproportionate rates of both homelessness and substance use, yet little research has examined the overlap of these issues in the ED setting. We aimed to characterize alcohol and drug use in a sample of homeless vs. non-homeless ED patients. MethodsA random sample of urban hospital ED patients were invited to complete an interview regarding housing, substance use, and other health and social factors. We compared substance use characteristics among patients who did vs. did not report current literal (streets/shelter) homelessness. Additional analyses were performed using a broader definition of homelessness in the past 12-months. ResultsPatients who were currently homeless (n = 316, 13.7%) versus non-homeless (n = 1,993, 86.3%) had higher rates of past year unhealthy alcohol use (44.4% vs. 30.5%, p < .0001), any drug use (40.8% vs. 18.8%, p < .0001), heroin use (16.7% vs. 3.8%, p < .0001), prescription opioid use (12.5% vs. 4.4%, p < .0001), and lifetime opioid overdose (15.8% vs. 3.7%, p < .0001). In multivariable analyses, current homelessness remained significantly associated with unhealthy alcohol use, AUDIT scores among unhealthy alcohol users, any drug use, heroin use, and opioid overdose; past 12-month homelessness was additionally associated with DAST-10 scores among drug users and prescription opioid use. ConclusionsPatients experiencing homelessness have higher rates and greater severity of alcohol and drug use than other ED patients across a range of measures. These findings have implications for planning services for patients with concurrent substance use and housing problems.

Disaster-related communication preferences of homeless and nonhomeless VA patients.

To identify the communication preferences of homeless (H) and nonhomeless (NH) Veterans Affairs (VA) patients for receiving information about the impact of natural disasters on VA healthcare services. Probability-based sampling design stratified on age categories, urban/rural, coastal/noncoastal, and homelessness. Northeast United States. Eligible NH and H participants included those who lived in and had at least one healthcare visit to a VA medical center/clinic in the region in the previous 24 months. Homeless participants included those receiving VA homeless services or having ICD9-CM V60.0 (Lack of Housing). 2,264/6,088 NH and 383/2,000 H completed the survey. Cross-sectional, mixed-mode survey administered August-November 2015. Helpfulness of ten communication modes for receiving information about the impact of natural disasters on VA healthcare services. Despite sociodemographic and health status differences, the top five communication modes rated extremely/very helpful were the same for both groups: telephone (76 percent H; 81 percent NH), TV (63 percent H; 60 percent NH), text (62 percent H; 50 percent NH), e-mail (56 percent H; 58 percent NH), radio (54 percent H; 47 percent NH). Newspaper and online modes (VA/other Web sites, Twitter, Facebook, MyHealtheVet) were rated substantially lower. H and NH patients prefer similar communication modes for receiving updates about the impact of natural disasters on VA healthcare services. Findings suggest that a multimodal communication strategy that incorporates phone, TV, text, e-mail, and radio will help Veterans Affairs (VA) reach its diverse patient population during natural disasters. Dissemination of messages via online modes, while rated less helpful, may augment the number of patients reached.

Utilization patterns of substance abuse and mental health resources at an urban VA Hospital

Background: Over 10% of the 610,000 homeless persons in the United States are veterans. Homelessness is associated with more substance abuse and mental health diagnoses, and higher hospitalization rates. We assessed the mental health (MH) and substance abuse (SA) burden and use of outpatient MH and SA resources in a homeless veteran population. Methods: Electronic medical record data were obtained on all homeless PACT team (HPACT) and non-homeless patients during fiscal years 2016 &2017. MH and SA prevalence, and related outpatient resource use were compared in three sub-populations: HPACT patients, non-HPACT patients with a homelessness ICD-10 code, and non-homeless PACT patients. Chi-square analyses and t-testing were performed to identify between-group differences during fiscal year 2018. Results: HPACT and homeless, non-HPACT patients had higher MH and SA disorder prevalence, and MH/SA comorbidity in both years (p

Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study.

BackgroundLittle is known about homeless patients in intensive care units (ICUs).ObjectivesTo compare clinical characteristics, treatments, and outcomes of homeless to non-homeless patients admitted to four ICUs in a large inner-city academic hospital.Methods63 randomly-selected homeless compared to 63 age-, sex-, and admitting-ICU-matched non-homeless patients.ResultsCompared to matched non-homeless, homeless patients (average age 48±12 years, 90% male, 87% admitted by ambulance, 56% mechanically ventilated, average APACHE II 17) had similar comorbidities and illness severity except for increased alcohol (70% vs 17%,p<0.001) and illicit drug(46% vs 8%,p<0.001) use and less documented hypertension (16% vs 40%,p = 0.005) or prescription medications (48% vs 67%,p<0.05). Intensity of ICU interventions was similar except for higher thiamine (71% vs 21%,p<0.0001) and nicotine (38% vs 14%,p = 0.004) prescriptions. Homeless patients exhibited significantly lower Glasgow Coma Scores and significantly more bacterial respiratory cultures. Longer durations of antibiotics, vasopressors/inotropes, ventilation, ICU and hospital lengths of stay were not statistically different, but homeless patients had higher hospital mortality (29% vs 8%,p = 0.005). Review of all deaths disclosed that withdrawal of life-sustaining therapy occurred in similar clinical circumstances and proportions in both groups, regardless of family involvement. Using multivariable logistic regression, homelessness did not appear to be an independent predictor of hospital mortality.ConclusionsHomeless patients, admitted to ICU matched to non-homeless patients by age and sex (characteristics most commonly used by clinicians), have higher hospital mortality despite similar comorbidities and illness severity. Trends to longer durations of life supports may have contributed to the higher mortality. Additional research is required to validate this higher mortality and develop strategies to improve outcomes in this vulnerable population.

Abstract P260: Patients Experiencing Homelessness Have Longer Hospital Lengths of Stay After Admission for Ischemic Stroke or TIA

Introduction: There is little information available regarding stroke care and outcomes specific to patients experiencing homelessness. This study assesses the provision of stroke care and outcomes for these patients and identifies opportunities to improve their care. Methods: Data was obtained from a large, multi-state health system’s Get With The Guidelines registry for patients discharged between January 2009 and September 2016. Patients with an ischemic stroke or transient ischemic attack (TIA) were included. Patients with time of last known well (LKW) to hospital arrival of more than two weeks or hospital arrival to CT times of more than two days were excluded. Homeless patients were matched to non-homeless patients with a 1:5 ratio using case control matching on age, stroke type, gender and year. Patient characteristics between homeless and housed patients were compared before and after matching using t-tests, Mann Whitney tests, or chi-squared tests, as appropriate. Primary outcomes were discharge modified Rankin score (mRs), with disability categorized as none/slight (mRs≤2) or moderate or greater (mRS &gt; 3) and length of stay (LOS). Logistic regression was used to analyze the relationship between homeless status and mRs, and Cox proportional hazards regression was used to assess the effect of homelessness on LOS. LKW to hospital arrival time and admit National Institutes of Health Stroke Scale (NIHSS) score were added as covariates to both models. Adjusted odds ratios (AOR) and hazards ratios (AHR), and their corresponding p-values were reported. Results: A total of 20,516 patients met inclusion criteria with 28 experiencing homelessness. Prior to matching, homeless patients were more likely to be male (78.6% vs 48.9%, p=.007), younger (58 vs 72 years, p&lt;.001) and have longer median LKW to arrival times (921 vs 386 minutes, p=.066). After matching, the analytic sample size was 168 patients with 16.7% (n=28) experiencing homelessness and 83.3% (n=140) housed. Multivariable analyses indicated that homeless patients leave the hospital at a slower rate compared to the non-homeless (AHR=0.666, p=.056). They also had lower disability scores at discharge (AOR=0.104, p=.095); however, this result only approached significance. Conclusion: Patients experiencing homelessness had longer LKW to hospital arrival times indicating an opportunity for targeted intervention around the need for quick arrival after symptoms. In addition, homeless patients also had longer LOS which is likely related to challenges in safely discharging this population. Further research with a larger number of patients is needed in order to compare other aspects of acute stroke care, including treatment rates and time to treatment, and assess ways to address the challenges of shortening last known well to arrival times and safe discharge.

Tuberculosis among the homeless: should we change the strategy?

Tuberculosis (TB) is a major concern among high-risk populations such as the homeless. To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless. This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression. TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection. TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.