Rates of mental illness, problematic substance use, and chronic medical conditions are high in homeless populations (Beijer et al. 2012; Fazel et al. 2014). Despite their acute and prevalent health problems, people experiencing homelessness frequently encounter barriers to accessing treatment and managing their conditions (Hwang et al. 2011; Krausz et al. 2013). The consequences of health service inaccessibility are not limited to homeless people who need care but also manifest in healthcare systems through inefficiencies and higher costs. Greater use of emergency departments (EDs) by people experiencing homelessness compared to the general population is among the most common, systemic burdens associated with this issue (Hwang et al. 2013; Ku et al. 2010; Mitchell et al. 2017; Salhi et al. 2018). People experiencing homelessness also have higher rates of returns to EDs within 72 h and ED visits within seven days of hospital discharges (Ku et al. 2010). These service use patterns suggest that received treatment and care does not meet their healthcare needs, possibly contributing to the “revolving door syndrome.”
As in the general population, a small proportion of people experiencing homelessness accounts for the majority of ED use. In a Canadian 4-year prospective cohort study of homeless adults, the top decile of ED users had 60.3% of the total ED visits in the sample (Chambers et al. 2013). Similar patterns have been observed in U.S. studies, with 7.9% of homeless and marginally housed people accounting for 55% of all ED visits in a sample from San Francisco (Kushel et al. 2002) and 21% of people experiencing homelessness having 73% of ED visits in a Boston sample (Lin et al. 2015). Poorer health status is most consistently associated with frequent ED use, though unmet mental healthcare needs, psychiatric hospitalization histories, substance use problems, hepatitis C virus, and recent arrests have also been linked to frequent ED visits among the homeless population (Chambers et al. 2013; Kushel et al. 2002; Lin et al. 2015; Thakarar et al. 2015). Overall, frequent ED users who are homeless represent a highly marginalized population with complex health needs, which may not be adequately addressed by ambulatory healthcare services despite repeated use.
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