New to care: demands on a health system when homeless veterans are enrolled in a medical home model.

OBJECTIVES: We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. METHODS: We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. RESULTS: We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. CONCLUSIONS: Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

Losing work: regional unemployment and its effect on homeless demographic characteristics, needs, and health care.

BACKGROUND: Who becomes homeless because of unemployment and what they need are poorly understood. METHODS: Four-year time-series study. Homeless characteristics, co-morbid conditions, and needs are correlated with unemployment rates. RESULTS: The unemployment rate averaged 6.7% during years 1-2 (N=198) and 11.8% during years 3-4 (N=202). Those presenting during high unemployment worked most recently in clerical positions (10.4% vs. 4.5%, p= .02) and reported unemployment (OR=2.0; 95% CI; 1.07, 3.76) and unaffordable housing (28.7% vs. 15.2%; p<.01) causing homelessness. Those reporting unemployment were more likely to be local residents (OR=2.1; CI=1.01, 4.53), but less likely to have family support (OR=0.4; CI=0.19, 0.87). While comparable proportions reported mental health conditions and received care, more high unemployment individuals reported needing additional care (59.9% vs. 42.9%; p<.001) and that this was necessary for leaving homelessness (58.9% vs. 44.1%; p=.05). CONCLUSIONS: High unemployment expands the population vulnerable to homelessness and influences health care needs and social needs.

Aversion to injection limits acceptability of extended-release naltrexone among homeless, alcohol-dependent patients.

BACKGROUND: Ending homelessness is a major priority of the Department of Veteran Affairs (VA), and alcohol use can be a barrier to stable housing. Clinical trials suggest that depot extended-release naltrexone (XR-NTX) is efficacious in reducing alcohol consumption among alcohol-dependent subjects. METHODS: An open-label, randomized pilot study sought to examine the feasibility and effectiveness of XR-NTX versus oral naltrexone to improve alcohol consumption and housing stability among homeless, alcohol-dependent veterans at the Providence Veteran Affairs Medical Center. RESULTS: Of 215 potential candidates approached over a 16-month recruitment period, only 15 agreed to consider study entry and 7 were randomized. The primary reasons given for refusal were not wanting an injection; fear of needles; and not wanting to change drinking habits. Only 1 participant in the XR-NTX group returned after the first injection. Three participants in the oral naltrexone group attended all 7 visits and had good outcomes. CONCLUSIONS: Although XR-NTX has demonstrated efficacy in reducing heavy drinking, limited acceptance of the injection might reduce its effectiveness among homeless, alcohol-dependent patients.

Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes.

OBJECTIVES: We compared a population-tailored approach to primary care for homeless veterans with a usual care approach. METHODS: We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care. RESULTS: Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01). CONCLUSIONS: Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.