Professional Documents
Culture Documents
Academic Emergency Medicine - 2008 - D Amore - The Epidemiology of The Homeless Population and Its Impact On An Urban
Academic Emergency Medicine - 2008 - D Amore - The Epidemiology of The Homeless Population and Its Impact On An Urban
Academic Emergency Medicine - 2008 - D Amore - The Epidemiology of The Homeless Population and Its Impact On An Urban
Abstract. Objectives: To characterize the homeless 95% confidence intervals (95% CIs) are given where
adult population of an urban emergency department appropriate: mean age (⫾SD) = 42 ⫾ 10 vs 48 ⫾ 13;
(ED) and study the medical, psychiatric, and social male gender 95% vs 54% (OR = 17; 95% CI = 8 to 37);
factors that contribute to homelessness. Methods: A history of (hx) tuberculosis 49% vs 15% (OR = 2.5;
prospective, case–control survey of all homeless adult 95% CI = 1.2 to 3); hx HIV infection 35% vs 13% (OR
patients presenting to an urban, tertiary care ED and = 3.8; 95% CI = 1.8 to 8); hx penetrating trauma 62%
a random set of non-homeless controls over an eight- vs 16% (OR = 8.62; 95% CI = 4.4 to 17.1); hx depres-
week period during summer 1999. Research assis- sion 70% vs 15% (OR = 13.4; 95% CI = 6.7 to 27); hx
tants administered a 50-item questionnaire and were schizophrenia 27% vs 7% (OR = 5.1; 95% CI = 2.0 to
trained in assessing dentition and triceps skin-fold 14); hx alcoholism 81% vs 15% (OR = 24; 95% CI =
thickness. Inclusion criteria: all homeless adults who 12 to 49); significant tooth loss (>3) 43% vs 18% (OR
consented to participate. Homelessness was defined = 3.3; 95% CI = 1.8 to 6.4); percentage of body fat
as being present for any person not residing at a pri- 16.5% vs 19.7%; hx social isolation (no weekly social
vate address, group home, or drug treatment pro- contacts) 81% vs 11% (OR = 33.3; 95% CI = 14 to 100);
gram. Randomly selected controls were concurrently mean number of ED visits/year 6.0 vs 1.6. Conclu-
enrolled with a 3:1 homeless:control rate. Exclusion sions: In the study population homelessness was as-
criteria: critically ill, injured, or incapacitated pa- sociated with a history of significantly higher rates of
tients, or patients <21 years of age. Univariate anal- infectious disease, ethanol and substance use, psy-
ysis with appropriate statistical tests was used. The chiatric illness, social isolation, and rates of ED uti-
Mantel-Haenszel test was used to adjust for popula- lization. Key words: homeless; public health; epi-
tion differences. Results: Two hundred fifty-two demiology; urban medicne; emergency department.
homeless subjects and 88 controls were enrolled. ACADEMIC EMERGENCY MEDICINE 2001; 8:
Data are presented for homeless vs control patients, 1051–1055
and all p-values were <0.01. Odds ratios (ORs) with
RESULTS
Over an eight-week period from June to August
1999, 252 homeless patients and 88 non-homeless
controls were enrolled in the study.
TABLE 1. Utilization of Health Care Resources by the gration into society. In pilot studies, such ap-
Homeless Population and the Control Patients
proaches have been very successful, resulting in
Health Care Resource Homeless Control p-value decreased ED utilization, improved access to pri-
mary care, and an overall decrease in homeless-
Primary physician (%) 7.5 82 <0.01
Regular clinic (%) 28 83 <0.01 ness by as much as 57%.12,13 Even without a com-
Shelter avoidance (%) 30 n/a n/a plex case management system, it has been shown
Median no. emergency that by creating ‘‘compassionate,’’ goal-directed
department visits/year care for the homeless, reliance on the ED can be
(25th, 75th percentiles) 6.1 (3, 9) 1.0 (1, 4) <0.01 reduced.14 Given the fact that a majority of EDs do
Mean no. admissions/year
(% with >3/year) 2.4 (25%) 0.25 (5.5%) <0.01
not even have 24-hour in-house social work staff,
this approach would require a significant reallo-
cation of resources.
TABLE 2. Relative Risks Associated with Homelessness In extreme cases where individuals place them-
selves or others in clear and present danger (i.e.:
Disease Process Relative Risk 95% CI chronic debilitating alcoholism), it may be neces-
Tuberculosis 2.5 1.2, 3 sary to institute mandatory commitment under
HIV-positive 3.8 1.8, 8 9.39 of the New York State mental health code, not
Depression 13.4 6.7, 27 for the sole purpose of treating any dangerous
Alcoholism 24 12, 49
medical condition, but for intensive social rehabil-
Schizophrenia 5.1 2, 14
Social isolation 33.3 14, 100 itation. This unique approach has been imple-
Assault victim 8.62 4.4, 17 mented several times in our institution for se-
verely debilitated alcoholic individuals whose
frequency of ED presentation averaged once per
cial conditions is provided along with 95% confi- day and who presented a clear and present danger
dence intervals (95% CIs). to themselves and others secondary to their alco-
holism. The standard approach of a ‘‘social admis-
sion’’ was an inadequate gesture because most in-
DISCUSSION patient teams were unable to address the patient’s
myriad needs and because the patients often
In our study population homelessness was associ- signed out against medical advice shortly after ad-
ated with extremely high rates of medical illness mission. When these patients were committed to a
(35% HIV-positive, 49% with TB), psychiatric ill- locked psychiatric unit, they were able to receive
ness (27% schizophrenia, 70% depression), alco- needed medical and psychiatric care and could be
holism (81%), substance use (36% use heroin, 35% placed in outpatient programs with close follow-up
use cocaine), and social isolation (81%). The home- under court mandate. This approach was success-
less population is not integrated into a primary ful in re-uniting at least one individual with his
care system, which results in overutilization of the family, although it has not been proven in any type
ED and high rates of hospitalization. Although of prospective study.
66% of the homeless population (in this study) uses A successful example of this type of program is
existing public assistance programs, these primar- the directly observed therapy (DOT) program for
ily financial subsidies do not address the pervasive the treatment of TB. This program involves com-
medical and social concerns of this population. Ad- munity-based and clinic-based DOT workers who
ditionally, placement into long-term shelters does administer TB medication under direct observa-
not solve the complex medical and psychosocial tion. Patients are served with a co-DOT (health
problems facing the homeless. Approximately 60– commissioner’s order for DOT), and in cases where
70% of our homeless population resides in a shel- the patients are noncompliant with outpatient
ter, a facility adjacent to our hospital in which DOT, they are subject to detention in a locked fa-
many of the men have resided for several years. cility for the duration of their therapy. Of all pa-
However, other than food, shelter, and rudimen- tients served with a co-DOT between 1993 and
tary social services, there are essentially no organ- 1996, only 8% required detention for noncompli-
ized on-site programs that focus on reintegrating ance. In the same time period, there was a 34%
these people into society. Shelter-based programs drop in the overall number of TB cases and a re-
also fail to reach the 30% of our homeless popula- duction of multiple-drug-resistant TB by 75%.15
tion who avoid the shelter system entirely. The application of this type of intensive program
One possible approach would be to implement expanded to include medical, psychiatric, and so-
an intensive case management approach to home- cial interventions under a single aegis could dras-
lessness wherein each homeless individual would tically alter the size and acuity of the homeless
be assigned to a case manager to facilitate reinte- population.
15532712, 2001, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2001.tb01114.x by Cochrane Mexico, Wiley Online Library on [23/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ACADEMIC EMERGENCY MEDICINE • November 2001, Volume 8, Number 11 1055
An integrated two-tiered system would be the and substance abuse along with their attendant
most efficacious. Homeless persons presenting to risks to themselves and the rest of society will ul-
the ED would be assigned dedicated case mana- timately determine the future for this large popu-
gers who would be responsible for coordinating all lation of patients. These patients exist in our cities
aspects of their care: housing, drug treatment, pri- wandering from ED to ED and hospital to hospital
mary care, entitlements, and employment. Those without social, medical, or psychiatric contact.
individuals refractory to this approach who repre- Only when a critical incident or problem inter-
sent a clear and present danger to themselves or venes are they brought to the attention of health
others (due to infectious/psychiatric disease, or care providers, usually for focused, short-term in-
profoundly maladaptive behavior) would be man- terventions with subsequent discharge to their
dated to undergo a period of intense inpatient hos- previous environment. This approach leads to a vi-
pitalization focusing on detoxification, treatment, cious circle of ED recidivism, continued homeless-
and rehabilitation. These individuals would rep- ness, and excessive morbidity and mortality.
resent the most debilitated of the homeless popu- There is little question that the homeless pop-
lation who, in such an impaired condition due to ulation places an incredible financial and social
alcohol, substance use, or untreated psychiatric ill- burden on society. The real challenge lies not in
ness, arguably lack clear decisional capacity. In quantifying the problem, but in organizing and al-
this manner those individuals who continually locating the essential public resources that will be
‘‘fall through the cracks’’ could be assisted. This ap- necessary to combat this critical epidemic. Given
proach would need to be supported by a body of the immense social and financial costs of untreated
case law, and ultimately new legislature. homelessness, the investment would be more than
cost-effective.
The primary limitation of this study is the subjec- 1. Link BG, Susser E, Steuve A. Lifetime and five year prev-
alence of homelessness in the United States [abstract]. Am J
tive nature of data reporting. No attempt was Public Health. 1994; 84:1907.
made to objectively validate the answers to survey 2. Homelessness in New York State. Albany, NY: New York
questions. Therefore, there may be some over/un- State Department of Social Services, 1984; vol I:6–10.
3. Gelberg L, Linn L, Smith MH. Health, homelessness, and
derstatements of certain types of information. poverty: a study of clinic users. Arch Intern Med. 1990; 150:
However, previous research has determined that 2325–30.
self-reporting by homeless persons on medical is- 4. Arch S, Leake B, Knowles L, Gelberg L. Tuberculosis in
homeless patients: potential for case finding in public emer-
sues is relatively accurate.16,17 The close proximity gency departments. Ann Emerg Med. 1998; 32:144–7.
(three city blocks) of our center to a large homeless 5. Susser E, Valencia E, Conover C. Prevalence of HIV infec-
tion among psychiatric patients in a New York City men’s shel-
men’s shelter of approximately 1,000 beds acts as ter. Am J Public Health. 1993; 83:568–70.
a significant referral bias and may explain why 6. Wrenn S. Immersion foot: a problem of the homeless in the
there were so few female homeless subjects. There 1990’s. Arch Intern Med. 1991; 151:785–8.
7. Padgett DK, Struening EL, Andrews H. Predictors of emer-
may also be significant external validity issues gency use by homeless adults in New York City: the influence
since this is only a single center study with a sig- of predisposing, enabling, and need factors. Soc Sci Med. 1995;
nificantly higher volume of homeless patients than 41:547–56.
8. Gallagher TC, Anderson RM, Koegel P. Determinants of reg-
may be seen at other centers. The homeless pop- ular sources of care among homeless adults in Los Angeles.
ulation in this study may also be significantly more Med Care. 1997; 35:814–30.
9. Hibbs JR, Brenner L, Klugman L. Mortality of homeless
compromised than homeless populations found adults in Philadelphia. N Engl J Med. 1994; 331:305–9.
elsewhere. A national, multicenter study would be 10. Salit SA, Kuhn EM, Hartz AJ. Hospitalization costs asso-
a logical next step. Finally, at our institution all ciated with homelessness in New York City. N Engl J Med.
1998; 338:1734–40.
patients with a primary psychiatric complaint are 11. Goldfrank L. Caring for homeless patients: challenge for
triaged to a psychiatric assessment area (annual the 90’s [abstract]. Hosp Physician. 1991; 4:13.
volume 6,000 to 8,000). The fact that these pa- 12. Okin RL, Boccelar A, Azocar F. The effects of clinical case
management on hospital service use among frequent ED users.
tients were not included in the survey may serve Am J Emerg Med. 2000; 18:603–8.
to significantly underestimate the psychiatric con- 13. Plumb JD, McManus P, Carson L. A collaborative com-
munity approach to homeless care. Prim Care Clin. 1996; 23(1):
ditions of both homeless and control populations. 17–25.
14. Redelmeier DA, Molin JP, Tibshirani RJ. A randomized
trial of compassionate care for the homeless in an emergency
CONCLUSIONS department. J Accid Emerg Med. 1996; 13:415–7.
15. Fujiwara P, Larkin C, Frieden TR. Directly observed ther-
apy in New York City: history, implementation, results, and
The resolution of the battle between the civil lib- challenges. Clin Chest Med. 1997; 18(1):135–48.
erty to be homeless and the societal obligation to 16. Gelberg L, Siecke N. Accuracy of homeless adults self-re-
ports. Med Care. 1997; 35:287–90.
care for men and women who suffer from un- 17. Anderson R, Kasper J, Frankel MR. Total Survey Error.
treated psychosis, TB, HIV infection, alcoholism, San Francisco, CA: Jossey-Bass Publishers, 1979.