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emergency department use, health care, health insurance, health care services, homeless adults, primary care visit



  1. Han, Beth
  2. Wells, Barbara L.


This study tested whether the use of the Health Care for the Homeless Program (HCHP) by homeless adults was associated with reduced risk of inappropriate emergency department (ED) use. Researchers interviewed 941 homeless adults at 52 soup kitchens. Of those interviewed, 508 reported having at least 1 ED visit during the last 6 months. Then, 243 subjects' 688 ED records were retrieved. Inappropriateness of each ED use was evaluated based on clinical criteria. Logistic regressions were applied. Having two or more HCHP visits [odds ratio (OR) = 0.43, 95% confidence interval (CI) 0.19, 0.90] by homeless adults was associated with decreased odds of having inappropriate ED visits.


Among the general population, reasons for self-referral to hospital emergency departments (EDs) involve interactions of social, economic, psychological, and medical factors. 1-4 Among homeless people, reasons for ED use for inappropriate care may be even more complex. Homeless people face numerous barriers to receiving health care and have high rates of illness and disability. 5,6 EDs have frequently been primary, rather than emergency, sources of health care for homeless persons. 7-9 Based on the Behavioral Model of Health Services, 10 difficulty in getting health care and frequent ED visits might be strong enabling factors for inappropriate ED use. However, having recent hospitalization history was associated with appropriate ED use. 1-4 Previous studies showed that homeless people were more likely to overuse emergency departments for nonurgent care. 11,12 The increasing number of ED visits for nonurgent care results in ED overcrowding and long ED waiting time, which restrict access to needed emergency care. 13


The number of persons experiencing homelessness in the United States has grown tremendously over the past 20 years. 14 In addition to EDs, other health care safety net providers that deliver comprehensive care for homeless persons are needed. One of the major federally supported programs that provide health care services funding for homeless people is the Health Care for the Homeless Program (HCHP). HCHP-funded grantees are required to provide primary health care, substance abuse services, outreach services, enabling services, case management, preventive dental care, and referrals to housing services for homeless persons. 15,16 Moreover, HCHP grantees are required to refer patients for needed mental health care to their collaborating organizations if they can not directly provide these services at their sites. The HCHP has provided continuing support for 137 grantees in 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, and has provided services to approximately 500,000 homeless people in 2001.


Previous research has not assessed whether the use of the HCHP services by homeless persons is associated with lower risk of inappropriate use of EDs. In theory, the HCHP, which provides the medical home for homeless persons, should have the ability to divert their inappropriate use of EDs. Nevertheless, this premise has not been tested. The primary purpose of this study was to examine whether the use of HCHP services by homeless adults was associated with their reduced risk of inappropriate ED use.