Use of Medical Services By Homeless Persons With Psychiatric and Co-Occurring Disorders

Purpose: High rates of medical problems and premature mortality have been found among homeless persons with psychiatric and co-occurring disorders.  Despite these medical problems, 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 at the 12-month follow-up period in the federal ACCESS (Access to Community Care and Effective Services and Supports) demonstration project.  The ACCESS project remains 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 traditional (e.g., race, education, social supports) and vulnerable (e.g., psychiatric symptoms, substance use, public benefits) domain variables on the use of outpatient and emergency medical services.  It was predicted that after 12 months of involvement in the assertive case management services of the ACCESS project, that participants would evidence lower use of emergency medical services and higher use of outpatient medical services.

Methods: This study was a secondary analysis of the national ACCESS participant database that involved 6,398 participants who completed a 12-month follow-up interview with the project.  The ACCESS project 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 emergency and outpatient medical services at 12-months after involvement in the project.   

Results:  When compared with use of outpatient medical services, higher alcohol severity scores predicted higher use of emergency medical services (OR = 3.00; CI = 2.03-4.42, p = 0.016).  Also, participants with higher psychiatric symptom scores used more emergency medical services than outpatient medical services (OR = 2.22, CI = 1.515-3.25, p < 0.001).  Participants who reported having a case manager were more likely to use outpatient medical services rather than emergency medical services (OR = 1.32; 1.14-1.52, p < 0.001), and those who stayed were in a shelter for 60 consecutive nights were more likely receive outpatient medical services than emergency medical services (OR = 1.22; CI = 1.06-1.39, p = 0.005).

Implications: This follow-up study of participants in the federal ACCESS initiative provides empirical evidence that alcohol use and psychiatric symptom severity predicts use of emergency medical services.  Receipt of case management services and use of shelters were found to enhance participants’ use of outpatient medical services.  These findings illustrate the value of providing assertive outreach and case management services to homeless persons who have psychiatric disorders.  These programs can help link homeless people with psychiatric and co-occurring disorders with medical services that they need and help to further reduce the costly use of emergency medical services.  Implications of these findings for social work research, practice and policy are explored.