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      Difficult Behaviors in the Emergency Department: A Cohort Study of Housed, Homeless and Alcohol Dependent Individuals

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      PLoS ONE

      Public Library of Science

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          Abstract

          Background

          This study contrasted annual rates of difficult behaviours in emergency departments among cohorts of individuals who were homeless and low-income housed and examined predictors of these events.

          Methods

          Interviews in 1999 with men who were chronically homeless with drinking problems (CHDP) (n = 50), men from the general homeless population (GH) (n = 61), and men residing in low-income housing (LIH) (n = 58) were linked to catchment area emergency department records (n = 2817) from 1994 to 1999. Interview and hospital data were linked to measures of difficult behaviours.

          Results

          Among the CHDP group, annual rates of visits with difficult behaviours were 5.46; this was 13.4 (95% CI 10.3–16.5) and 14.3 (95% CI 11.2–17.3) times higher than the GH and LIH groups. Difficult behaviour incidents included physical violence, verbal abuse, uncooperativeness, drug seeking, difficult histories and security involvement. Difficult behaviours made up 57.54% (95% CI 55.43–59.65%), 24% (95% CI 19–29%), and 20% (95% CI 16–24%) of CHDP, GH and LIH visits. Among GH and LIH groups, 87% to 95% were never involved in verbal abuse or violence. Intoxication increased all difficult behaviours while decreasing drug seeking and leaving without being seen. Verbal abuse and violence were less likely among those housed, with odds ratios of 0.24 (0.08, 0.72) and 0.32 (0.15, 0.69), respectively.

          Conclusions

          Violence and difficult behaviours are much higher among chronically homeless men with drinking problems than general homeless and low-income housed populations. They are concentrated among subgroups of individuals. Intoxication is the strongest predictor of difficult behaviour incidents.

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          Most cited references 28

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          Factors associated with the health care utilization of homeless persons.

           Margot Kushel (2001)
          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. To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. 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. 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). 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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            Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.

            Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.
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              Homelessness and health.

               Shin Hwang (2001)
              Homelessness affects tens of thousands of canadians and has important health implications. Homeless people are at increased risk of dying prematurely and suffer from a wide range of health problems, including seizures, chronic obstructive pulmonary disease, musculoskeletal disorders, tuberculosis, and skin and foot problems. Homeless people also face significant barriers that impair their access to health care. More research is needed to identify better ways to deliver care to this population.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                28 April 2015
                2015
                : 10
                : 4
                Affiliations
                Department of Family and Community Medicine, University of Toronto, Centre for Research on Inner-City Health, Li Ka Shing Knowledge Institute—St. Michael’s Hospital, Toronto, Canada
                University of California San Diego, UNITED STATES
                Author notes

                Competing Interests: The author has declared that no competing interests exist.

                Conceived and designed the experiments: TS. Analyzed the data: TS. Contributed reagents/materials/analysis tools: TS. Wrote the paper: TS.

                Article
                PONE-D-14-32856
                10.1371/journal.pone.0124528
                4412575
                25919015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                Page count
                Figures: 0, Tables: 6, Pages: 13
                Product
                Funding
                This work was supported by grants from the Central East Health Information Partnership, the former City of Toronto Shelter, Housing and Support Division, Physician Services Incorporated, and St. Michael's Hospital Research Department as well as a post-doctoral fellowship from the Canadian Institutes for Health Research to Tomislav Svoboda.
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                Research Article
                Custom metadata
                All relevant data are within the paper.

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