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1.
Breakey WR, Fischer PJ, Kramer M.  et al.  Health and mental health problems of homeless men and women in Baltimore.  JAMA.1989;262:1352-1357.Google Scholar
2.
Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons.  Am Psychol.1991;46:1115-1128.Google Scholar
3.
Koegel P, Burnam MA, Farr RK. The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles.  Arch Gen Psychiatry.1988;45:1085-1092.Google Scholar
4.
Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario.  JAMA.2000;283:2152-2157.Google Scholar
5.
Barrow SM, Herman DB, Cordova P, Struening EL. Mortality among homeless shelter residents in New York City.  Am J Public Health.1999;89:529-534.Google Scholar
6.
Hibbs JR, Benner L, Klugman L.  et al.  Mortality in a cohort of homeless adults in Philadelphia.  N Engl J Med.1994;331:304-309.Google Scholar
7.
Hwang SW, Lebow JM, Bierer MF.  et al.  Risk factors for death in homeless adults in Boston.  Arch Intern Med.1998;158:1454-1460.Google Scholar
8.
Martell JV, Seitz RS, Harada JK.  et al.  Hospitalization in an urban homeless population.  Ann Intern Med.1992;116:299-303.Google Scholar
9.
Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City.  N Engl J Med.1998;338:1734-1740.Google Scholar
10.
Ein Lewin M, Altman S. America's Health Care Safety NetWashington, DC: National Academy Press; 2000.
11.
Fischer PJ, Shapiro S, Breakey WR, Anthony JC, Kramer M. Mental health and social characteristics of the homeless.  Am J Public Health.1986;76:519-524.Google Scholar
12.
Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles.  Am J Public Health.1997;87:217-220.Google Scholar
13.
Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations.  Health Serv Res.2000;34:1273-1302.Google Scholar
14.
Duchon LM, Weitzman BC, Shinn M. The relationship of residential instability to medical care utilization among poor mothers in New York City.  Med Care.1999;37:1282-1293.Google Scholar
15.
O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Preferences for sites of care among urban homeless and housed poor adults.  J Gen Intern Med.1999;14:599-605.Google Scholar
16.
Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults.  Med Care.1990;28:805-821.Google Scholar
17.
Rosenheck R, Seibyl CL. Homelessness.  Med Care.1998;36:1256-1264.Google Scholar
18.
 National Survey of Homeless Assistance Providers and Clients: Public Use Data Files Clients. Washington, DC: Census Bureau; 1999. Available at: http://www.census.gov/prod/www/nshapc/NSHAPC4a.html. Accessed December 6, 2000.
19.
US Congress.  Stewart B. McKinney Homeless Assistance Act. Pub L No. 100-77; 1987.
20.
Tourkin S, Hubble D. National Survey of Homeless Assistance Providers and ClientsWashington, DC: US Dept of the Census; 1997.
21.
McLellan AT, Kushner H, Metzger D.  et al.  The Fifth Edition of the Addiction Severity Index.  J Subst Abuse Treat.1992;9:199-213.Google Scholar
22.
Argeriou M, McCarty D, Mulvey K, Daley M. Use of the Addiction Severity Index with homeless substance abusers.  J Subst Abuse Treat.1994;11:359-365.Google Scholar
23.
Zanis DA, McLellan AT, Canaan RA, Randall M. Reliability and validity of the Addiction Severity Index with a homeless sample.  J Subst Abuse Treat.1994;11:541-548.Google Scholar
24.
Burt M, Aran L, Douglas T.  et al. for the Urban Institute.  Homelessness: Programs and the People They ServeWashington, DC: Urban Institute; 1999.
25.
US Congress.  Veteran's Health Care Eligibility Reform Act of 1996. Pub L No. 104-262; 1996. Available at: http://www.va.gov/health/elig/eligibility.html. Accessed November 28, 2000.
26.
Krauss NA, Kass BL. Use of Health Care Services, 1996Rockville, Md: Agency for Health Care Policy and Research; 1999. AHCPR publication 99-0018.
27.
Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los Angeles.  Med Care.1997;35:814-830.Google Scholar
28.
Padgett DK, Struening EL, Andrews H, Pittman J. Predictors of emergency room use by homeless adults in New York City.  Soc Sci Med.1995;41:547-556.Google Scholar
29.
Padgett DK, Struening EL. Influence of substance abuse and mental disorders on emergency room use by homeless adults.  Hosp Community Psychiatry.1991;42:834-838.Google Scholar
30.
Wenzel SL, Bakhtiar L, Caskey NH.  et al.  Homeless veterans' utilization of medical, psychiatric, and substance abuse services.  Med Care.1995;33:1132-1144.Google Scholar
31.
National Center for Health Statistics.  Health, United States, 1998Washington, DC: Government Printing Office; 1998. DHHS publication 98-1232-1. Available at: http://www.cdc.gov/nchs/data/huscht98.pdf. Accessed November 28, 2000.
32.
O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Utilization of health care services among subgroups of urban homeless and housed poor.  J Health Polit Policy Law.1999;24:91-114.Google Scholar
33.
Kreider B, Nicholson S. Health insurance and the homeless.  Health Econ.1997;6:31-41.Google Scholar
34.
Long SH, Marquis MS. The uninsured "access gap" and the cost of universal coverage.  Health Aff (Millwood).1994;13:211-220.Google Scholar
35.
Forrest CB, Starfield B. Entry into primary care and continuity.  Am J Public Health.1998;88:1330-1336.Google Scholar
36.
Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Health insurance and access to primary care for children.  N Engl J Med.1998;338:513-519.Google Scholar
37.
Glied S, Hoven C, Moore RE, Garrett AB. Medicaid and service use among homeless adults.  Inquiry.1998;35:380-388.Google Scholar
38.
Gelberg L, Linn LS. Social and physical health of homeless adults previously treated for mental health problems.  Hosp Community Psychiatry.1988;39:510-516.Google Scholar
39.
Gelberg L, Linn LS. Psychological distress among homeless adults.  J Nerv Ment Dis.1989;177:291-295.Google Scholar
40.
Pearson SD, Katzelnick DJ, Simon GE, Manning WG, Helstad CP, Henk HJ. Depression among high utilizers of medical care.  J Gen Intern Med.1999;14:461-468.Google Scholar
41.
Fischer P. Alcohol, Drug Abuse and Mental Health Problems Among Homeless PersonsRockville, Md: Dept of Health and Human Services; 1991.
42.
Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California.  Am J Public Health.1997;87:221-228.Google Scholar
43.
Zolopa AR, Hahn JA, Gorter R.  et al.  HIV and tuberculosis infection in San Francisco's homeless adults.  JAMA.1994;272:455-461.Google Scholar
44.
Gelberg L, Siecke N. Accuracy of homeless adults' self-reports.  Med Care.1997;35:287-290.Google Scholar
45.
Andersen R, Kasper J, Frankel MR. Total Survey ErrorSan Francisco, Calif: Jossey-Bass Publishers; 1979.
Caring for the Uninsured and Underinsured
January 10, 2001

Factors Associated With the Health Care Utilization of Homeless Persons

Author Affiliations

Author Affiliations: Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine (Drs Kushel and Haas), Department of Epidemiology and Biostatistics (Dr Vittinghoff), Institute for Health Policy Studies (Dr Haas), University of California, San Francisco.

 

Caring for the Uninsured and Underinsured Section Editors: William L. Roper, MD, MPH, University of North Carolina at Chapel Hill; Carin M. Olson, MD, Contributing Editor, JAMA.

JAMA. 2001;285(2):200-206. doi:10.1001/jama.285.2.200
Abstract

Context Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective.

Objective To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons.

Design and Setting Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients.

Subjects A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996.

Main Outcome Measures Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year.

Results Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75).

Conclusions In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.

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