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Correspondence: Address correspondence to Paul A. Nakonezny, PhD, Center for Biostatistics & Clinical Science and Department of Psychiatry, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8828. E-mail: paul.nakonezny{at}utsouthwestern.edu
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Abstract |
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Key Words: Homeless person • Health service • Indigenous health services
11302(a). To be homeless, however, means more than to lack a domicile; it is a symptom of personal and societal disaffiliation. It is estimated that there are between 1 and 2 million homeless people in the United States (National Coalition for the Homeless, 1999), representing a wide variety of individuals: single men, single women, couples with children, single women with children, adolescents (e.g., runaways), and older adults (Gillis & Singer, 1997). Of the homeless population in the United States, about 25% are older adults over the age of 50 years (Rossi, 1989). The rates of both acute and chronic health problems are high among the U.S. homeless population (Amarasingham, Spalding, & Anderson, 2001; Wojtusik & White, 1998), and the prevalence of morbidity increases with age (Gelberg, Linn, & Mayer-Oakes, 1990). Substance abuse, acute infections, musculoskeletal problems, hypertension, mental illness, dermatologic disease, and trauma are common among older individuals who are homeless (Amarasingham et al.; Wojtusik & White). Previous researchers (e.g., Crane, 1996) have found that older homeless adults have a greater need for health services, in part because they are more likely than younger homeless individuals to be in poorer health, but, because they have limited access to health services, these health problems often go untreated or treatment is delayed. Access to health services by homeless adults is usually limited by such factors as lack of transportation; lack of self-efficacy to compete for social and health services in the traditional institutional setting; and lack of outreach health services that are geared toward the special needs of homeless adults (Gillis & Singer, 1997; Sachs-Ericsson, Wise, Debrody, & Paniucki, 1999). Thus, for many homeless individuals, the county hospital and emergency room setting remains the source of usual, nonemergency, medical care, even though this setting is not an ideal mode of delivery for individuals who are homeless to receive primary health care services (Gillis & Singer).
To augment access to health care and to mitigate the burden on the hospital and emergency room setting, county hospitals have to explore nontraditional, ambulatory modes of health services delivery that are targeted specifically to the homeless population. One alternative model being used by the Parkland Health and Hospital System in Dallas, Texas—a large county hospital—is the Homeless Outreach Medical Services (HOMES) program, which uses two mobile medical units and a fixed-site outpatient clinic to provide primary health care to homeless individuals.
Our purpose in the current study was to examine the relationship between health services utilization delivered by means of the HOMES program and health services utilization delivered by means of the Parkland emergency room and inpatient units among a sample of older and younger homeless adults being served by the Parkland Health and Hospital System. Specifically, given greater access to health services by means of the HOMES program, homeless persons will, we predict, have greater outpatient utilization than inpatient utilization for the disease conditions addressed in this study. We also expect that older homeless adults will have greater utilization of health services than younger homeless individuals.
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Methods |
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The HOMES program uses two 40-ft (12.18 m)-long mobile medical units (MMUs) and a fixed-site outpatient clinic to provide primary health care on a walk-in, no-charge basis to individuals who are homeless. The HOMES program targets areas in Dallas County, Texas, where homeless individuals congregate. Primary care is provided by physicians, nurses, nurse practitioners, mental health professionals, registered dietitians, and social workers. Homeless patients who require health care that cannot be delivered through the HOMES program are referred to the appropriate units within the Parkland Health and Hospital System.
Design and Sample
We used a quasi-experimental design, and we randomly selected health services utilization data from 293 male (50.4%) and 288 female (49.6%) homeless patients from among the 14,876 homeless patients aged 20–64 years who used HOMES and the Parkland Health and Hospital System between June 1, 1992, and June 30, 1999. A sample size of 581 permitted an estimation of the true population mean utilization to within ± 1.5 units of utilization with 95% confidence (Cochran, 1977). The homeless patients in the current sample (and in the HOMES system) included the sheltered homeless and the unsheltered homeless. Subject characteristics, including those by age group, are reported in Table 1.
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We measured outpatient utilization as the number of visits to the HOMES MMUs and fixed-site outreach clinic, and we measured inpatient utilization as the number of visits to the Parkland emergency room and inpatient units. Over a 7-year time period from June 1992 to June 1999, we tracked each homeless patient's inpatient and outpatient utilization for psychiatric, substance abuse, and musculoskeletal conditions.
Independent Variables
To test the relationship between age and health services utilization, we divided the sample into two groups: young and old. We defined younger homeless adults as being 20 to 49 years of age and older homeless adults as being 50 to 64 years of age, with 20 years and 64 years representing the youngest age and oldest age, respectively, of a homeless patient in the current sample. Previous homeless research suggests that the minimum age demarcation of 50 years for an older homeless adult is meaningful, because the biopsychological characteristics of homeless individuals tend to resemble those of adults in the general population who are 10 to 20 years older (Cohen, Teresi, & Holmes, 1988; Doolin, 1986).
Data Analysis
Our primary data analysis was a split-plot repeated measures multivariate analysis of variance (MANOVA), with Age (young, old) serving as a between-subjects factor and Unit (outpatient, inpatient) serving as a within-subjects factor. We conducted a separate repeated measures MANOVA for each of the three disease conditions (psychiatric, substance abuse, and musculoskeletal). We used the repeated measures MANOVA design to assess the main effect of age on the difference in health services utilization (outpatient utilization minus inpatient utilization) over the 7-year time period. We also used an analysis of variance (ANOVA) to assess the main effect of age on inpatient utilization and on outpatient utilization averaged over the 7-year period. We performed a separate ANOVA for each of the three disease conditions. As a secondary analysis, we used simple linear regression to test the relationship between age (continuously measured) and inpatient and outpatient utilization for each of the three disease conditions.
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Results |
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A simple linear regression also revealed a significant relationship between age and the HOMES MMU outpatient substance abuse utilization, b =.35, ß =.19, t(188) = 2.70, p <.007, and between age and the HOMES MMU outpatient musculoskeletal utilization, b =.47, ß =.18, t(192) = 2.60, p <.01 (Table 3). The regression results, however, indicated no significant relation between age and inpatient utilization for homeless substance abuse patients, b =.09, ß =.10, t(188) = 1.38, p <.16, and for homeless musculoskeletal patients, b =.03, ß =.04, t(192) = 0.62, p <.53.
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Discussion |
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The utilization of health services by homeless adults at the HOMES program, as reported in this study, is akin to that of other homeless individuals at similar types of homeless outreach programs in other U.S. cities (as reported by previous research): The Health Care for the Homeless Program in Los Angeles (Gelberg, Doblin, & Leake, 1996), The Street Outreach Services Program in San Francisco (Wojtusik & White, 1998), Project Rescue in New York City (Cohen, Onserud, & Monaco, 1992), and a free homeless outpatient clinic in a small Florida community (Sachs-Ericsson et al., 1999). The current study, like previous research, suggests that homeless adults receiving care from an accessible homeless outreach program, which is designed to address their special needs, will indeed utilize the health services and return for subsequent visits.
The findings of the current study also indicate that older homeless adults had significantly greater psychiatric inpatient utilization than younger homeless individuals. This pattern is in line with that of previous research (Kushel, Vittinghoff, & Hass, 2001; Padgett, Struening, & Andrews, 1990). Padgett and colleagues (1990) found that, when homeless individuals utilized mental health services, they did so more in the inpatient setting and less in the ambulatory setting (perhaps because of the more severe types of psychiatric conditions prevalent among the homeless population and the lack of requisite mental health services provided in the ambulatory setting to treat these conditions). Although homeless adults utilized HOMES for psychiatric care—most likely for psychiatric care that could be addressed by HOMES, for medication administration, and for an entry point to accessing the County's Medicaid mental health units—the use of inpatient services for psychiatric-related conditions perhaps, also, suggests a greater severity or progression of mental illness among older homeless adults (Duffy, Bissonnette, O'Brien, & Townsend, 1996). Given the more severe psychiatric conditions that were indeed found among the homeless adults in the current study (e.g., schizophrenia, severe depression, and manic-depressive disorder), these older homeless individuals (who could not be treated by means of the HOMES facilities) were referred to the appropriate psychiatric inpatient unit within the Parkland Hospital system by HOMES. Further, we presume that some of these older homeless adults returned for subsequent psychiatric visits at the Parkland emergency room setting and not at the HOMES facilities.
The current study found no significant gender and racial differences by age for psychiatric, substance abuse, and musculoskeletal services utilization (results are not shown, but they can be obtained from the corresponding author). This finding does not suggest that the prevalence of psychiatric, substance abuse, and musculoskeletal conditions is not affected by gender and race. Rather, what this finding suggests is that the distribution of gender and race by age is not significantly influencing the utilization of the health services targeted to homeless individuals. This finding is consistent with a few previous studies that are based on health services utilization patterns of homeless adults at other homeless outreach clinics (Sachs-Ericsson et al., 1999; Wojtusik & White, 1998).
The results of this study may be tempered by the nature of the study. The design and analysis, as in any quasi-experimental setting, cannot logically rule out the possibility that other factors besides the HOMES program either combined with or independently influenced the health services utilization patterns during the study period. It is hard to imagine a more salient individual influence besides the HOMES program, however, that might have plausibly affected health services utilization among the homeless patients in the current study over a 7-year period. Finally, broadly generalizing the results to homeless populations is beyond the scope of this study. The statistical analyses, however, may support generalizing to settings that appear similar to those in the current study.
Health services utilization among the homeless population is an underdeveloped area of research. There especially exits a dearth of research examining outreach efforts (such as MMUs) and health services acquisition among older homeless adults. Although prior research has addressed utilization patterns of homeless individuals at homeless outreach programs, these prior studies have primarily relied on cross-sectional designs with samples of younger homeless adults. The current study is unique, and different from previous research, in that we track the same group of both older and younger homeless adults over a 7-year period and we examine their health services utilization patterns at both the HOMES program and the Parkland emergency room and inpatient units. Although the current study is a step toward addressing paucity in the literature, future research concerning homeless adults' health needs and health outcomes associated with outreach medical care is needed. A logical next phase in this line of programmatic research of the HOMES program is to address cost assessment and health-related outcomes associated with health care delivery. Possible outcomes to address in future research would include the assessment of health care delivery cost; medication cost; improvement in symptoms associated with psychiatric, substance abuse, and musculoskeletal conditions; and global assessment of functioning and quality of life.
Implications and Conclusion
A significant void exists between the medical needs of the older homeless population and the current health care system in the United States. The HOMES program is an example of a health care delivery model that addresses the complex and unique health care needs of individuals who are homeless. If hospital systems and the community are to be successful in meeting the health care needs of the homeless population, they must develop programs that are accessible—so that health problems do not go untreated—and they must build a social support network for homeless adults to break down the social isolation barrier. These programs also must be designed with sensitivity to the special needs associated with homelessness.
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Footnotes |
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1 Center for Biostatistics & Clinical Science and Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas.
2 Parkland Health & Hospital System and Texas Woman's University, Dallas.
Decision Editor: Linda S. Noelker, PhD
Received for publication January 6, 2004. Accepted for publication October 4, 2004.
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11302 (1994).
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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| All GSA journals | Journals of Gerontology Series A: Biological Sciences and Medical Sciences | Journals of Gerontology Series B: Psychological Sciences and Social Sciences |
