Gender Differences in Predictors Impacting High Emergency Department Use Among Homeless to Housed Individuals

Background and Purpose: In the United States, individuals experiencing homelessness are three times more likely to use the Emergency Department (ED) than non-homeless individuals. ED use is higher among homeless males than homeless females. Research evidence has identified mental health and substance use needs as risk factors for ED use and housing as a protective factor for ED use among homeless individuals. However, individuals continue to use ED even after housing is secured and less is known about the factors impacting post-housing ED use, particularly for high ED utilizers. Although studies have reported the ongoing need for homeless services after housing placements, service utilization as a predictor of post-housing high ED use has not been examined in detail. This study examined service predictors impacting high ED utilization for homeless to housed individuals, focusing on gender differences.

Methods: A sample of 209 participants (ages 23-77) was selected from a mental health organization providing housing services in Texas between December 2019 to November 2021. The outcome variable, High ED use (Y/N), was measured by four or more ED visits in the past 12 months. Independent variables included demographics, mental health diagnosis (Adjustment Disorders, Alcohol-Related Disorders, Anxiety Disorders, Schizophrenia or other Psychotic Disorders, Substance-Related Disorders, Bipolar Disorder, Major Depressive Disorder), homeless services (Case Management, Counseling, Crisis, Psychosocial Rehabilitation, Peer, and Outpatient Substance Use), and total homeless service utilization. Logistic regression was conducted to identify predictors associated with high ED use.

Results: Overall, 31.6% of the participants were high ED users. 57.3% (121) were male, with a mean age of 50.51. For males, significant predictors of high ED use were Alcohol-Related Disorders (OR=2.94, p<.05), Substance-Related Disorders (OR=3.31, p<.01), Impulse Control Disorders (OR=15.1, p<.05), less Psychosocial Rehabilitation Services (OR=.91, p<.05), less Peer Services (OR=.89, p<.05), and greater total homeless service usage (OR=1.08, p<.05). For females, participants with Anxiety Disorders (OR=7.15, p<.05) and Substance-Related Disorders (OR=6.59, p<.01) were more likely to be a high ER utilizer.

Conclusions and Implications: Findings from this study portray that despite homeless services provided, there was a lack of Psychosocial Rehabilitation Services and Peer Services for males, which were associated with high ED use among males post-housing placements. Service providers should consider these factors to provide adequate Psychosocial Rehabilitation and Peer Services when making post-housing service delivery recommendations to decrease ED use. The high incidence of repeated post-housing ED use for males with Alcohol and Substance Use Disorders and females with Alcohol-Related Disorders identify a pressing need for practice and policy remedies that focus on Substance Use Services. Lastly, high rates of Anxiety Disorders among high ED users among females suggest the need for tailored interventions post-housing to ensure stability.