Housing the chronically sick homeless cuts healthcare costs
Two studies from the US have shown that housing interventions for homeless people with significant medical problems can help reduce demand on healthcare and other services.
In the first study, Larimer et al recruited 134 homeless people with coexisting alcohol problems to a housing project. Participants were offered housing on a ‘first found, first offered' principle. Ninety five were admitted to the housing project within three months of referral, and were considered a ‘treatment group', while a further 39 had to be placed on a waiting list and were treated as a control group. The housing project was characterised by minimal barriers to entrance, and no requirement for sobriety or for treatment attendance.
With consent, the researchers obtained specific itemised data relating to healthcare and criminal justice costs incurred by participants, using a variety of official sources.
Data included days in jail, emergency department visits, inpatient stays, outpatient contacts, medical detoxification and inpatient drug and alcohol treatment.
Following adjustment for a number of variables researchers found a total cost reduction of 53% for housed participants relative to waiting list controls (rate ratio, 0.47; 95% CI, 0.25-0.88) over the first six months of the study.
In the second paper, Sadowski et al conducted a randomised controlled study of patients discharged from two hospitals in Chicago. Participants had been homeless for a median of 30 months. They were all adults, without childcare responsibilities, who had at least one significant chronic medical illness. Two hundred and one participants were randomised to an intervention group and received ongoing case management input from social workers which included discharge to respite care followed by help with subsequent placement in stable housing. A further 206 patients were allocated to usual care and received routine discharge planning with transport to an overnight shelter if no other accommodation could be arranged, but with no continued housing support by social workers.
Of the 176 intervention participants alive at 18 months, 116 had reached stable housing and 15 were in prison. Of the 181 usual care participants alive at 18 months, only 19 had reached stable housing and 16 were in prison.
After adjusting for a range of variables, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalisations (95% CI, 10-44%), 29% fewer days spent in hospital (95% CI, 8-45%), and a 24% reduction in emergency department visits (95% CI, 3-40%).
Although there were slight improvements in physical function and mental health scores in the intervention group when compared with those who received usual care, the differences did not reach statistical significance.
These studies show that active support for housing homeless people who have significant medical problems can be effective in reducing demand on healthcare and other services.
Larimer ME, Malone, DK, Garner MD et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009; 301:1349-1357
Sadowski LS, Kee RA, VanderWeele TJ et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults. JAMA 2009; 301:1771-1778Reviewer
Dr Jez Thompson
GP and Clinical Director, NHS Hull Social Inclusion Services