The number of emergency department visits by people experiencing homelessness has more than doubled in the last decade while housed populations have remained about the same, according to the U.S. Centers for Disease Control and Prevention.
This makes understanding what types of programs are successful at reducing these rates of frequent emergency department utilization among the homeless, especially those with mental health conditions, important for future solutions.
A recent scoping review by student researchers at the University of Colorado School of Medicine shows that while programs tend to address the issue in various ways, housing first models and programs that focus on care management — both fairly popular solutions — do report overall success in driving down rates of frequent emergency department visits.
Housing and care management
“Research has consistently demonstrated that homeless patients face a heightened risk of returning to the ED (emergency department) within 30 days of their last visit or being readmitted to the hospital,” the paper, published this month in the Journal of Urban Health, explains. “The risk is further exacerbated with the diagnosis of a mental health condition.”
In working with the emergency department at UCHealth to determine which populations were high-utilizers and how best to determine housing status from patients, Rebekah Davis, MPH, a third-year medical student at CU and lead author of the paper, says she kept finding herself reading more about programs around the world that seek to combat frequent use. That building interest in quantifying what worked best, by how much, and why led to the review.
To be included in the review, programs had to describe or evaluate an intervention that was piloted in the emergency department, focus specifically on the homeless population, and target patients experiencing mental health challenges.
That left Davis with 14 programs in four countries — Australia, Canada, France, and the U.S — to analyze. Nine focused on housing support, four focused on care management, and one used electroconvulsive therapy. Many of the programs had mixed components, showcasing the complexity of the issue.
“Participants of these programs are struggling with a multitude of factors working against them,” Davis says. “Overcoming one challenge, such as the housing piece, is not enough to equate survival and success. Process improvement can make a difference in people’s lives, and how that’s achieved is looking at the outcomes from various projects.”
Six of the nine housing intervention studies found fewer emergency department visits among housing intervention groups while seven of the eight studies that assessed hospitalizations noted fewer hospital admissions and hospital inpatient days with housing intervention.
All four studies that primarily assessed care management interventions noted fewer emergency department visits among the care management intervention groups. Three of these studies also noted fewer hospitalizations.
The study focused on electroconvulsive therapy reported it was successful by decreasing participant suicidal ideation, suicide attempts, and fewer emergency department visits at both 30- and 90-days following treatment.
Overall, two of the studies found no change in emergency department visits.
Identifying favorable factors
Davis, who plans to focus on serving the unhoused and other vulnerable populations in her career as a primary care physician, says the review has meaningful takeaways for health care systems and those who are designing programs that target unhoused patients in emergency departments.
“A lot of public health projects get some flack for not having rigorously measured outcomes or not having evidence to encourage continued support ,” she says. “Papers like these are important to make sure there’s convincing evidence for projects that work to decrease the effects of social determinants of health, especially when it might not be monetarily beneficial in the beginning. To be able to think about the bigger picture and additional factors helps to back their continuation, and to be able to provide quantitative and qualitative evidence really goes a long way. When you consider the balance sheet, we need programs that make sense and are effective.”
While the more tailored programs saw more success, Davis says in the review that more studies are needed to determine the best strategies for specific populations and how to promote health equity among people experiencing homelessness with mental health conditions.
“It’d be great to see more peer support in health care systems and further investigate what contributes to those successes so that others can learn from that,” she says.
