Psychiatric–Medical ComorbidityUnmet need for medical care among homeless adults with serious mental illness
Introduction
People who are homeless have substantially higher rates of not only mental disorders [1], [2], [3] but also medical morbidity [4], [5] and mortality [6], [7], [8] than do those in the general population. However, despite their poorer health status and considerable need for medical care, homeless persons underuse outpatient medical services [9], [10] and rely to a greater extent on emergency department visits [11], [12] and costly inpatient hospitalizations [13], [14], often for preventable medical problems [15]. This pattern of health service use — one that is shifted away from ambulatory care toward more acute hospital-based care — reflects the substantial barriers faced by homeless individuals in obtaining timely and appropriate outpatient general medical services [16].
Considerable prior research has focused on determining rates and predictors of medical service use in the homeless population [9], [16], [17], [18], [19], [20], [21], [22], [23], [24]. Although these access-and-use studies have been important in identifying factors associated with receiving at least some minimal level of care, they do not address the extent to which homeless persons perceive their medical care needs as being unmet. To date, this issue of unmet need for medical services in the homeless population has received relatively minimal explicit attention [16], [25], [26].
In a study of reproductive-aged homeless women in Los Angeles, for example, Lewis et al. [26] found that 37% responded affirmatively to the question, “In the past 60 days, was there any time when you needed to see a doctor or nurse practitioner but didn't?” Cross-sectional correlates of an unmet health care need included history of drug abuse, lack of regular source of care, having children, poorer health status and perceived barriers to care. The study was limited, however, in that it included only a narrow segment of the homeless population in a single geographic area, affecting its generalizability. In another study, Kushel et al. [16] analyzed data from the 1996 National Survey of Homeless Assistance Providers and Clients and found that one quarter (24.6%) of homeless respondents reported having been unable to obtain needed medical care during the past year. Among the somewhat limited number of sociodemographic and clinical characteristics examined, lack of insurance and having more comorbid medical illnesses were associated with increased likelihood of reporting an unmet need.
In the present study, we used data from a multisite homeless case management demonstration project to address two objectives. First, we examined baseline data to determine the prevalence and correlates of subjective unmet need for medical care among homeless adults at the time of program entry. Second, going beyond the available cross-sectional literature, we analyzed 3-month follow-up data to determine the extent to which clients with an unmet need at baseline received ambulatory medical care during follow-up. In particular, we were interested in determining whether factors such as changes in substance abuse and psychiatric symptoms, linking with mental health treatment services, number of potentially competing needs and level of therapeutic alliance with the primary case manager affected the odds of receipt of medical services among those with a baseline unmet need. The findings of this study are expected to aid in developing and targeting strategies to identify and link vulnerable, seriously mentally ill homeless persons with needed medical services.
Section snippets
Data source and study sample
This study used data from the 5-year, 18-site Access to Community Care and Effective Services and Supports (ACCESS) homeless demonstration program, which has been described in detail elsewhere [27]. Briefly, all sites received funding to establish both specialized outreach teams to make contact with untreated homeless adults and intensive case management teams to provide comprehensive services for up to 1 year to approximately 100 new clients each year.
Over the 4-year recruitment period, 7530
Results
Baseline sample characteristics are summarized in Table 1. As Fig. 1 shows, 43.6% of the sample reported having an unmet need for medical care at baseline, with 26.0% reporting no need and 30.4% reporting an at least minimally met need.
Among those with an unmet medical need at baseline (n=3147), we sought to determine the proportion who continued to have an unmet need following program entry — defined as reporting no ambulatory medical care at follow-up. However, follow-up data were missing for
Discussion
In this study, more than 40% of homeless clients reported having an unmet need for medical care when they first entered the ACCESS program. Moreover, among those with a baseline unmet need, only approximately one third reported receiving a medical visit during the follow-up period. Previous research suggests that “competing priorities” may serve as a major barrier to obtaining needed medical services in the homeless population [38]. Consistent with this, we found that clients who reported
Acknowledgments
Dr. Desai is supported by a Career Development Award (MRP 02-259) from the Department of Veterans Affairs Health Services Research and Development Service.
This study was funded under interagency agreement AM-9512200A between the Center for Mental Health Services and the Department of Veterans Affairs Northeast Program Evaluation Center as well as through a contract between the Center for Mental Health Services and ROW Sciences (now part of Northrop Grumman) and subcontracts between ROW Sciences
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