More on Quality and Safety

Hospitalizations for homeless individuals are on the rise, driven by mental illness, substance abuse

Homeless adults were more often white, male, around 46 years old, and either uninsured or insured by Medicaid.

Jeff Lagasse, Associate Editor

Acute hospital use among the homeless is rising, driven largely by mental illness and substance use disorder, reveal findings recently published in the journal Medical Care.

A homeless individual is one who lacks fixed and reliable housing, and it is estimated that 553,000 people fit that description on any given night in the U.S.

The retrospective cohort study by investigators from Brigham and Women's Hospital and Beth Israel Deaconess Medical Center examined patterns, causes and outcomes of acute hospitalizations between 2007 and 2013 for homeless individuals and non-homeless control groups in three states: Florida, California and Massachusetts.


Between 2007 to 2013 -- 2011 for California -- acute hospitalizations for homeless people increased in all three states.

Massachusetts saw an increase from 294 to 420 per 1,000 homeless residents, Florida increased from 161 to 240/1,000, and California grew from 133 to 164/1,000.

Homeless adults were more often white (62 percent), male (76.1 percent), around 46 years old, and either uninsured (41.9 percent) or insured by Medicaid (31.7 percent).

Reasons for hospitalization among the two groups differed starkly. More than 50 percent of hospitalizations among homeless individuals were for mental illness and substance use disorder, while these conditions explained less than 20 percent of hospitalizations among demographically comparable non-homeless patients.

Homeless adults also had a longer mean length of stay (6.5 vs. 5.9 days). Yet homeless patients had lower in-hospital mortality rates (0.9 percent vs. 1.2 percent) and lower mean costs per day ($1,535 vs. $1,834) than the comparable non-homeless control group.


To examine these trends, hospital discharge data was acquired from Massachusetts and Florida between 2001 and 2013 and from California between 2007 and 2011. This information came from the State Inpatient Databases of the Healthcare Cost and Utilization Project, created by the Agency for Healthcare Research and Quality.

This dataset includes information such as homeless status, billing, demographics and diagnoses. Hospitalization costs were determined by applying American Hospital Association cost-to-charge ratios to the total hospital charges provided in the SID.


The findings mirror those of an earlier study, published in November, and have negative implications for resource use and utilization, and underscores the fact that mental illness and substance use disorder are still the main driver of acute hospitalizations among homeless adults.

Twitter: @JELagasse

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