Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

Abstract

IntroductionPatients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.MethodsWe conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients’ 30-day ED revisits and hospital readmissions.ResultsStudy included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).ConclusionHomeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.

Material Needs of Emergency Department Patients: A Systematic Review

“…Some studies attempted to use validated questionnaires for material needs. Most studies were cross‐sectional surveys, five were retrospective cohort studies, and three used prospective cohorts . Several studies described their methods as “case‐control” or “prospective” but were in fact cross‐sectional.…”

“…Local studies reported higher rates of homelessness than studies using NHAMCS. While the majority of local studies reported figures between 2.5 and 6%, homelessness rates were significantly higher in studies among high‐risk alcohol and drug users (22.8%), patients with psychiatric diagnoses in Arizona (22.3%), and patients at a public hospital ED near a homeless shelter in New York City (13.8%) . Several studies found an association between homelessness status and health services use (e.g., frequent ED use, hospital readmissions) …”

“…Studies varied considerably with respect to how they gathered material needs data. Twelve studies extracted material needs data from the medical chart or from a database, five of which used NHAMCS data . The remaining studies used self‐administered questionnaires or in‐person interviews.…”

Continuity of Care among People Experiencing Homelessness and Mental Illness: Does Community Follow‐up Reduce Rehospitalization?

“…). One American study, which examined hospital‐based service use 30‐days posthospital discharge found that rates of emergency department use and hospital readmission were higher among people experiencing both homelessness and mental illness as compared to other subpopulations (Lam, Arora, and Menchine ). Additionally, previous studies have found that among individuals with mental illnesses, while less likely to seek medical services overall, are more likely to seek medical care from urgent care settings (i.e., emergency departments) rather than via community‐based primary care (Pines et al.…”

“…). An American study found that the experience of homelessness and having a mental illness interacted to produce even higher levels of emergency department use and hospital readmission compared to those experiencing homelessness alone, mental illness alone, or neither (Lam, Arora, and Menchine ). More broadly, research findings have stimulated advocacy for increased emphasis and investments in continuity of care.…”