Small group of homeless people are extremely high users of ERs

Although homeless people account for a small proportion of Emergency Department visits, a small group of them are extremely high users and have multiple complex health care needs, new research has found.

During a four-year study conducted by St. Michael's Hospital, almost 900 had more than 8,500 ED visits, roughly two per person per year. But 60 per cent of those visits were made by only 10 per cent of the participants in the study, who had an average 12 trips to the ED each year. Compared to the low-income population of Toronto, homeless participants in this study visited an ED more than eight times as often.

The research led by Dr. Stephen Hwang of the hospital's Centre for Research on Inner City Health was published in three papers today in a special issue of the American Journal of Public Health devoted to homelessness and , one looking at the overall care use by and two others examining factors that predict frequent ED use and hospitalizations. All three papers used data from the Institute for Clinical Evaluative Sciences, where Dr. Hwang is an adjunct scientist.

The study also found that single homeless women were more likely than single homeless men to have made at least one ED visit during the study and that homeless adults with families (mostly women with dependent children) were far less likely to be frequent users.

Single homeless women generally have a higher prevalence of mental illness, while single homeless men have a higher prevalence of substance abuse. Homeless mothers generally have lower rates of both, which may partially explain why families in this study had lower rates of ED use.

Other factors significantly associated with any ED use were: being born in Canada, having higher monthly income, perceived unmet needs for , lack of belief in the ability to control one's health and poorer physical health status.

Immigrants and members of visible minority groups were half as likely to use ED services, possibly because homeless recent immigrants tend to be healthier than homeless people who are born in Canada. Dr. Hwang said it's also possible that factors related to language, awareness of services, socio-economic barriers and perceived discrimination or stigma may deter those individuals from visiting the ED.

Surprisingly, higher monthly incomes were associated with a greater likelihood of frequent ED use. Dr. Hwang said these individuals may be engaging in risk behaviours, such as binge drinking or drug use, following receipt of social support payments.

Dr. Hwang said previous studies have shown that interventions such as intensive case management or housing first programs, that move homeless people immediately into stable housing, have the potential to reduce ED use, lower costs and improve social and clinical outcomes among the frequent users. He said more research is needed to determine whether those interventions would also work for the general homeless population.

"Reducing frequent emergency health care use among homeless persons will require sustained efforts to reduce unmet needs for , particularly for mental health services, and improvement in the coordination of care across health and social services," he said.

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