The health, personal, and economic challenges that chronically homeless individuals face and the lack of effective, coordinated services to address these problems often lead to a vicious circle of housing instability and further deterioration of well-being. These individuals are often prevented from stabilizing in housing by their health conditions, while their persistent homelessness impedes their access to needed health and employment services. Consequently, they cycle through costly emergency-driven public systems, including emergency shelters, hospital emergency departments, detoxification centers, and criminal justice facilities, without getting the ongoing care they need to address severe mental illness, substance use disorders, or chronic health conditions (Proscio, 2000; Kushel, 2003; Kushel et al., 2005; Thornquist, 2002).
High Rates of Shelter Use, Inpatient Hospital Stays, and Emergency Room Visits
As would be expected given their long-term homeless status, people who are chronically homeless spend a disproportionate number of days in the shelter system compared to those who are homeless for shorter periods of time. Chronically homeless people are likely to be about half or more of individuals included in cross-sectional samples of homeless people living in shelters or on the streets, while they only comprise about 20 percent of all the people who use shelters over a three-year period (Metraux et al., 2001).
In addition, people who are chronically homeless are high utilizers of emergency and inpatient hospital services for medical, substance use, and mental health conditions. In Philadelphia, homeless mental health patients used more psychiatric acute care hospital days, outpatient emergency-crisis intervention services, substance abuse treatment, and inpatient hospital care for medical conditions than non-homeless mental health patients (Kuno et al., 2000). In San Diego, Folsom et al. (2005) found that homeless patients with severe mental illness were ten times more likely than housed consumers with severe mental illness to use crisis residential treatment and four times more likely to use inpatient psychiatric hospitals and psychiatric emergency units; however, they were less likely to use outpatient mental health services. In the same study, it was found that homeless people with schizophrenia who have a physical illness are less likely to be admitted to a hospital during the early, less severe phase of their illness and more likely to be admitted when the disease is more advanced and severe.
As the chronically homeless population ages, individuals are increasingly likely to visit a hospital emergency department or to have experienced an inpatient hospitalization for a medical problem in the prior year, reflecting increasing rates of chronic medical conditions in addition to high rates of mental health and substance use disorders (Hahn et al., 2006). Garibaldi, Conde-Martel, and OToole (2005) found that homeless persons over age 50 were 3.6 times more likely to report two or more chronic medical conditions, 2.4 times more likely to be dependent on heroin, and 1.8 times more likely to abuse alcohol.
Studies of frequent users of health care services also provide some additional clues that homelessness may lead to frequent and inappropriate use of hospital services. As part of the Frequent Users of Health Services Initiative, six California communities developed data on the number and characteristics of their frequent users. Each community identified a core group of individuals who repeatedly used hospital emergency departments (in some cases weekly), often for medical crises that could have been avoided with appropriate, ongoing care. Sometimes the presenting issue is not a medical crisis, but is related to a chronic health condition, mental illness, or a psychosocial issue, such as drug or alcohol use. Analyses of data related to these patients found that while the prevalence of patient characteristics varied from one county to another, high rates of mental illness, substance abuse problems, and homelessness were common. Among frequent user patients, 25 percent to 58 percent were homeless or lacked stable housing. Many were hospitalized but often failed to receive follow-up care and the social supports that could lead to genuine recovery (Corporation for Supportive Housing, 2005). In a study of frequent users of emergency department services at San Francisco General Hospital, 81 percent of study participants, who had five or more visits in the previous 12 months, were homeless. The majority had multiple serious medical illnesses that required ongoing health care (Shumway et al., in press).
Significant Involvement with the Criminal Justice System
Cycling through jail and prison is a common occurrence among people who experience chronic homelessness. Zugazawas recent study (2004) of sheltered homeless adults, in which 82 percent of men and 52 percent of women had histories of incarceration, illustrates this fact. With changing patterns in systems of public mental health care for people with severe and persistent mental illness, the significance of the criminal justice system has grown more prominent (Freudenberg, 2001). Indeed, it has been suggested that jails are de facto assuming responsibility for the care of a seriously disabled group whose needs cross over multiple systems of care. Metraux and Culhanes (2004) analysis of administrative data on persons released from state prisons to New York City revealed that among persons released with a prior history of shelter use, 45 percent reentered the shelter system following release from prison. Most shelter reentries occurred within a one-month period following release. Homelessness occurring in the post-release period was apparent among former inmates with histories of mental health treatment. Kushel et al. (2005) have reported elevated health risks, including drug use, HIV infection, HIV risk behaviors, and mental illness among homeless and marginally housed former prisoners. McNiel, Binder, and Robinson (2005) have observed that incarcerated people with histories of homelessness, mental illness, and substance use disorders experience an increased duration of incarceration.
Low Rates of Engagement and Retention in Outpatient Mental Health Services, Substance Abuse Treatment, and Appropriate Health Care
While chronically homeless individuals have high rates of emergency service utilization, they are generally unable to access and engage in ongoing outpatient treatment for mental illness, chronic health conditions, and substance use disorders. According to Fortney et al. (2003), homeless people with mental illness are more likely than other mental health consumers to experience less continuity of care as measured by longer duration between encounters for mental health services, lower volume of service encounters, fewer types of services received, lower likelihood of receiving continuous care from the same facility/provider, and lower likelihood of having a case manager. The authors note that low continuity of outpatient care over time puts people who are homeless and mentally ill at risk for encounters with other less appropriate elements of the service system, such as hospitals and emergency departments, as well as placing them at risk for encounters with the criminal justice system. This is confirmed by other studies that consistently document inefficient patterns of utilization among homeless patients with mental illness more days of acute psychiatric hospitalization, greater utilization of services in the psychiatric emergency units of hospitals, and more infrequent use of outpatient mental health services (Kuno et al., 2000; Rosenheck et al., 2003; Folsom et al., 2005).
Similarly, homeless individuals are more likely to cycle in and out of emergency and residential substance abuse treatment services and often find it difficult to maintain participation in outpatient settings. Homeless participants in substance abuse treatment services are more likely than other participants to receive detox or residential treatment and more likely to have had multiple episodes prior to the current treatment episode (Office of Applied Studies, SAMHSA, 2006). Homeless participants who enter substance abuse treatment programs are often unable or unwilling to complete the program. Studies of a range of treatment interventions found only about one-fourth (Castillo et al., 2005) to one-third (Orwin et al., 1999) of participants complete substance abuse treatment programs, even when the programs are specifically designed for homeless people with serious substance use problems.
Providing housing in conjunction with treatment significantly increases client retention (Orwin et al., 1999) and improves treatment outcomes (Kertesz et al., 2006). The National Institute on Alcohol Abuse and Alcoholism Cooperative Agreements for Research Demonstration Projects on Alcohol and Other Drug Abuse Treatment for Homeless Individuals tested 23 interventions in 14 sites. Eight of these sites offered some form of housing for one or more intervention groups, including residential treatment programs, supervised transitional housing, or other residential arrangements for treatment program participants. (This broad range of housing and treatment models included, but was not limited to, supportive housing, which is discussed later in this paper.) Discharge policies ranged from zero tolerance to zero consequences for relapse. Researchers found that all of the interventions lost two-thirds or more of participants prior to program completion, while residential interventions retained more individuals than nonresidential programs. In addition, homeless participants were more likely to complete treatment programs that are less intensive, more flexible, or designed as relatively brief (three to four months) interventions (Orwin et al., 1999). And while treatment-ready homeless clients may prefer intensive programs, others (the majority of chronically homeless people) are likely to stay longer in low-demand programs (Orwin et al., 1999).
In a study of long-term housing and work outcomes among homeless people who were using cocaine, Kertesz et al. (2006) compared outcomes for program participants who had been randomly assigned to live in a furnished apartment contingent upon drug abstinence, similar housing not contingent upon abstinence, and no housing during participation in a 6-month treatment program. Even though both housing interventions were available only during the 6-month period coinciding with treatment (a time frame significantly shorter than that allowed by most transitional housing programs), after 12 months participants who had received housing while in treatment had higher rates of both stable employment and stable housing, when compared to those who had not received housing assistance while in the same treatment program. Even so, the majority of treatment participants were unable to achieve stable housing after completing treatment.
Despite the individual barriers that homeless clients have, however, motivation may also play a key role in success in substance abuse treatment. Interventions to enhance motivation and readiness to change and seek treatment are likely to be helpful (Gonzalez & Rosenheck, 2002).
Among people living with HIV/AIDS, homelessness, active drug use, mental health problems, recent incarceration, and limited social support are all factors associated with an increased likelihood of delayed entry into appropriate medical care and dropping out of medical care, even after controlling for other demographic characteristics and risk factors. HIV-positive persons who are homeless are more likely to engage in high-risk sex and drug behaviors, and are more likely to have a high viral load, recent opportunistic infection, and hospitalization for HIV related disease (Aidala, 2006; Aidala & Needham-Waddell, 2006; Schubert & Botein, 2006).
High Public Costs for Ineffective Care
Emergency and inpatient health and psychiatric services carry a hefty price tag and are often more expensive than the ongoing outpatient and preventative treatment that people who are chronically homeless have a difficult time accessing. Including the costs of shelter use and incarceration, the public costs of chronic homelessness become exorbitant. Culhane et al. (2002) found that before placement into permanent supportive housing, 4,679 homeless people with severe mental illness used about $40,451 per year per person in services. More than 85 percent of these costs were associated with health care and mental health services primarily for care delivered in hospital settings. This is the largest study ever completed, but smaller studies in a range of communities found similarly high levels of costs for services to homeless (often chronically homeless) adults with disabilities.
A study of 151 homeless adults with serious mental illness in Baltimore found that total costs per person for in-patient and outpatient health care and treatment services averaged $26,193 to $33,827 (Lehman et al., 1999). Similarly, a pilot study of 35 chronically homeless adults with co-occurring mental illness and substance use problems in Portland, Oregon, estimated that pre-enrollment annual costs for health care and incarceration averaged $42,075 per person. More than 80 percent of total costs were associated with inpatient hospitalizations for medical care and emergency room visits (Moore, 2006). A study of Denvers Housing First Collaborative program (one of 11 projects funded in 2003 through the federal governments Collaborative Chronic Homelessness Initiative) found that the costs of health care services utilized in the two years before participants entered the program averaged $17,381 per participant, and 90 percent of these costs were associated with inpatient or emergency room care.
Studies of persons living on the streets and addicted to alcohol also show extremely high costs for health services (generally related to alcohol-related illness and injury), police intervention and incarceration, and detoxification services while homeless (Cox et al., 1998; Thornquist et al., 2002; Podymow et al., 2006). In San Diegos Serial Inebriate Program (SIP), rates of utilization of emergency room and inpatient hospital care among individuals served by the program were extraordinarily high. Charges for ambulance and hospital care provided to 529 SIP clients over a four-year period totaled $17.7 million, more than $8,000 per year per client (Dunford et al., 2006). Other studies of individuals among this population who were frequent users of detoxification services had very similar findings. In Seattle, medical charges for a sample of 298 people averaged more than $2.5 million per year during the three-year study, also more than $8,000 per year per person (Cox et al., 1998). In Minneapolis, Minnesota, the total annual charges for frequent users of detoxification services averaged $12,771 per person (Thornquist et al., 2002).