Medical Service Use Among Homeless Persons with Psychiatric and Co-Occurring Disorders
Purpose: Despite high rates of medical problems and premature mortality among homeless persons with psychiatric and co-occurring disorders, this subgroup has been found to underutilize outpatient and preventative medical services, and to use a high rate of emergency medical services. This study examined factors that predicted the use of emergency and outpatient medical services by homeless people with psychiatric and co-occurring disorders who participated in the federal ACCESS (Access to Community Care and Effective Services and Supports) demonstration project, the largest and most geographically representative database that exists on homeless persons with psychiatric disorders. The Gelberg-Andersen Behavioral Model for Vulnerable Populations was used as a conceptual framework to examine the impact that traditional (e.g., race, education, social supports) and vulnerable (e.g., psychiatric symptoms, substance use, public benefits) domain variables have on use of outpatient and emergency medical services. It was hypothesized that vulnerable domain factors would be important factors in the use of emergency medical services.
Methods:This study was a secondary analysis of the national ACCESS participant database that involved 7,229 participants who completed the initial baseline interview for the study. The ACCESS project was a national research demonstration project that provided assertive outreach and case management services to homeless persons with psychiatric and co-occurring disorders in eighteen sites in nine states across the United States from 1993-1999. Multinomial logistic regression analysis was used to examine factors that predicted the use of medical services in the sixty days prior to participants’ baseline interview.
Results:Alcohol use was higher among those who used emergency medical services when compared to those who used outpatient medical services (OR = 1.67; CI = 1.09-2.56, p = 0.018), no medical services (OR = 2.22, CI = 1.515-3.25, p < 0.001), and both outpatient and emergency medical services (OR = 1.87, CI = 1.19-2.92, p = 0.006). When compared to those who used emergency services, those who used outpatient medical services had more social supports (OR = 1.50; 1.15-1.96, p = 0.003), and were more likely to receive non-cash public support benefits (OR = 1.40; CI = 1.15-1.96, p < 0.001). Psychiatric symptom severity was positively associated with use of both outpatient and emergency medical services (OR = 1.67; CI = 1.16-2.39 p = 0.006) compared to those who used no services, outpatient services, and emergency room services.
Implications: This study provides empirical evidence that vulnerable domain variables (alcohol use, psychiatric symptoms, non-cash benefits) are important factors in examining use of medical services among homeless people with psychiatric and co-occurring disorders. In this large database, alcohol use was associated with higher use of emergency medical services when compared to all other groups of medical service use. These findings suggest the importance of assertive and innovative programs that provide outreach and case management services to homeless persons who have psychiatric disorders. These programs can integrate medical specialists or develop inter-agency collaborative relationships with agencies that provide medical services. The author further explores the implications of these findings for social work research, practice and policy.