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Research Letter |

Use of Acute Care Services Among Older Homeless Adults FREE

Rebecca T. Brown, MD, MPH1; Dan K. Kiely, MPH, MA2; Monica Bharel, MD, MPH3; Laura J. Grande, PhD4; Susan L. Mitchell, MD, MPH2
[+] Author Affiliations
1Division of Geriatrics, Department of Medicine, University of California, San Francisco
2Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
3Boston Health Care for the Homeless Program, Boston
4Psychology Service, Veterans Affairs Boston Healthcare System, Boston
JAMA Intern Med. 2013;173(19):1831-1834. doi:10.1001/jamainternmed.2013.6627.
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Published online

The median age of homeless single adults in the United States has increased from approximately 35 years in 1990 to nearly 50 years in 2010,1 yet little is known about health care utilization among older homeless adults. Homeless adults 50 years or older have unique medical problems, including high rates of chronic illnesses and geriatric conditions.2 A better understanding of the health care use by this vulnerable population would help to target strategies to improve their care. Thus, we prospectively observed a cohort of older homeless adults to describe and identify modifiable factors associated with emergency department (ED) visits and hospitalizations during a 1-year period.

In 2010, we recruited 250 homeless adults from 8 shelters in Boston.3 Eligibility criteria included age 50 years or older, current homelessness, and ability to communicate in English and provide informed consent. We conducted a baseline in-person assessment, and 12 months later we reviewed medical records at 10 Boston hospitals to determine the cohort’s use of acute care services in the intervening year.

Baseline study variables are detailed elsewhere.3 Data collected by interview included demographic characteristics, comorbidities, access to health care, alcohol problems (Addiction Severity Index [ASI] score ≥0.17), and drug problems (ASI score ≥0.10).4 We assessed common geriatric conditions by means of interview and physical examination, including activities of daily living, instrumental activities of daily living, falls during the past year, global cognitive impairment (Mini–Mental State Examination score <24),5 and executive dysfunction, defined as a Trail Making Test Part B duration more than 1.5 standard deviations above population-based norms or as stopping the test early.6 We also assessed frailty (Fried criteria)7; major depression (9-item Patient Health Questionnaire score ≥10)8; and sensory impairment, defined as self-reported difficulty hearing despite using a hearing aid, self-reported difficulty seeing despite wearing corrective lenses, or best-corrected visual acuity worse than 20/40.

After 12 months, investigators reviewed medical records at the 10 hospitals for each participant by name, date of birth, and social security number. If a matching medical record was found, investigators ascertained the number of ED visits and hospitalizations undergone by that participant during the past 12 months.

Multivariable logistic regression analysis was used to estimate the associations between baseline characteristics and 2 outcomes at 12 months: (1) at least 4 ED visits and (2) at least 1 hospitalization. Adjusted models included age, sex, and variables associated with the outcomes in bivariable analyses at a P value <.10. We conducted analyses using SAS, version 9.2 (SAS Institute).

The participants’ mean age was 56.2 years, 19.2% were female, and 40.0% were white (Table 1). After 12 months, 64.0% of participants had at least 1 ED visit (range, 0-112), and 28.4% had at least 4 ED visits; the participants who made at least 4 ED visits accounted for 86.2% of all ED visits made by the cohort (eTable in Supplement). In multivariable analysis, the following characteristics were significantly associated with making at least 4 ED visits: female sex (adjusted odds ratio [AOR], 2.9 [95% CI, 1.2-6.6]), white race (AOR, 2.6 [95% CI, 1.3-5.4]), no usual source of primary care (AOR, 2.5 [95% CI, 1.2-5.3]), at least 1 outpatient visit during the past year (AOR, 6.5 [95% CI, 1.2-34.4]), alcohol problem (AOR, 2.8 [95% CI, 1.2-6.5]), at least 1 fall during the past year (AOR, 2.9 [95% CI, 1.4-6.3]), executive dysfunction (AOR, 2.8 [95% CI, 1.3-5.8]), and sensory impairment (AOR, 3.1 [95% CI, 1.4-6.9]).

Table Graphic Jump LocationTable 1.  Predictors of Frequent Emergency Department Visits During a 12-Month Period Among 250 Older Homeless Adults

Eighty-four participants (33.6%) were hospitalized during the 12-month period (range, 0-38 hospitalizations). In multivariable analysis, the following characteristics were significantly associated with at least 1 hospitalization (Table 2): older age (AOR, 1.4 [95% CI, 1.1-1.8]), white race (AOR, 1.8 [95% CI, 1.0-3.4]), inability to see a health care provider when needed (AOR, 2.1 [95% CI, 1.0-4.6]), at least 1 clinic visit during the past year (AOR, 6.8 [95% CI, 1.5-30.2]), and sensory impairment (AOR, 2.0 [95% CI, 1.1-3.7]).

Table Graphic Jump LocationTable 2.  Predictors of Hospitalization During a 12-Month Period Among 250 Older Homeless Adults

This prospective study demonstrated that ED visits and hospitalizations are common among older homeless adults. Several modifiable factors were associated with greater use of acute care, including alcohol problems, past falls, and sensory impairment. In previous work, housing interventions have been shown to decrease acute care use among subgroups of homeless persons.9 Our results suggest that in programs serving the older homeless population, counseling on substance use, addressing risk factors for falls, and facilitating access to glasses or hearing aids may help avoid a substantial number of ED visits and hospitalizations.

The study has several limitations. We may not have captured all ED visits or hospitalizations, particularly if they occurred outside Boston. Moreover, because the study was conducted in Massachusetts, a state with universal health insurance, our results may not be generalizable to other states.

Providing primary care to older patients living in the street or a shelter is challenging. Focusing limited resources on targeting modifiable factors, including alcohol problems and common geriatric conditions, may lower rates of burdensome and costly acute care use in this vulnerable population.

Corresponding Author: Rebecca T. Brown, MD, MPH, San Francisco Veterans Affairs Medical Center, 4150 Clement St, 181G, San Francisco, CA 94122 (rebecca.brown@ucsf.edu)

Published Online: June 10, 2013. doi:10.1001/jamainternmed.2013.6627.

Author Contributions: Dr Brown had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Brown, Mitchell.

Acquisition of data: Brown, Bharel, Grande.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Brown, Grande, Mitchell.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Brown, Kiely.

Obtained funding: Mitchell.

Administrative, technical, and material support: Grande, Mitchell.

Study supervision: Bharel and Mitchell.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by National Institutes of Health grant NIH-NIA T32 AG000212 and the John A. Hartford Foundation. Dr Mitchell was supported by National Institutes of Health grant NIH-NIA K24 AG033640.

Additional Contributions: Mit Patel, MD (Department of Medicine, St Elizabeth’s Medical Center, Boston, Massachusetts), Kevin L. Ard, MD, MPH (Department of Medicine, Brigham and Women’s Hospital, Boston), Deborah Blazey-Martin, MD, MPH (Department of Medicine, Tufts Medical Center, Boston), and Daniella Floru, MD (Division of Geriatric Medicine, Lemuel Shattuck Hospital, Boston) completed medical record reviews and provided comments on the manuscript.

Culhane  DP, Metraux  S, Byrne  T, Stino  M, Bainbridge  J.  The age structure of contemporary homelessness: evidence and implications for public policy. Anal Soc Issues Public Policy. 2013;13(1):1-17.
Gelberg  L, Linn  LS, Mayer-Oakes  SA.  Differences in health status between older and younger homeless adults. J Am Geriatr Soc. 1990;38(11):1220-1229.
PubMed
Brown  RT, Kiely  DK, Bharel  M, Mitchell  SL.  Geriatric syndromes in older homeless adults. J Gen Intern Med. 2012;27(1):16-22.
PubMed   |  Link to Article
McLellan  AT, Kushner  H, Metzger  D,  et al.  The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9(3):199-213.
PubMed   |  Link to Article
Crum  RM, Anthony  JC, Bassett  SS, Folstein  MF.  Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993;269(18):2386-2391.
PubMed   |  Link to Article
Heaton  RK, Miller  W, Taylor  MJ, Grant  I. Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults. Lutz, Florida: Psychological Assessment Resources; 2004.
Fried  LP, Tangen  CM, Walston  J,  et al; Cardiovascular Health Study Collaborative Research Group.  Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156.
PubMed   |  Link to Article
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
PubMed   |  Link to Article
Larimer  ME, Malone  DK, Garner  MD,  et al.  Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349-1357.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Predictors of Frequent Emergency Department Visits During a 12-Month Period Among 250 Older Homeless Adults
Table Graphic Jump LocationTable 2.  Predictors of Hospitalization During a 12-Month Period Among 250 Older Homeless Adults

References

Culhane  DP, Metraux  S, Byrne  T, Stino  M, Bainbridge  J.  The age structure of contemporary homelessness: evidence and implications for public policy. Anal Soc Issues Public Policy. 2013;13(1):1-17.
Gelberg  L, Linn  LS, Mayer-Oakes  SA.  Differences in health status between older and younger homeless adults. J Am Geriatr Soc. 1990;38(11):1220-1229.
PubMed
Brown  RT, Kiely  DK, Bharel  M, Mitchell  SL.  Geriatric syndromes in older homeless adults. J Gen Intern Med. 2012;27(1):16-22.
PubMed   |  Link to Article
McLellan  AT, Kushner  H, Metzger  D,  et al.  The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9(3):199-213.
PubMed   |  Link to Article
Crum  RM, Anthony  JC, Bassett  SS, Folstein  MF.  Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993;269(18):2386-2391.
PubMed   |  Link to Article
Heaton  RK, Miller  W, Taylor  MJ, Grant  I. Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults. Lutz, Florida: Psychological Assessment Resources; 2004.
Fried  LP, Tangen  CM, Walston  J,  et al; Cardiovascular Health Study Collaborative Research Group.  Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156.
PubMed   |  Link to Article
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
PubMed   |  Link to Article
Larimer  ME, Malone  DK, Garner  MD,  et al.  Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349-1357.
PubMed   |  Link to Article

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