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The longer a person is homeless, the more likely he or she is to experience poor health and be placed at higher risk for premature death. This makes interventions early in one’s homelessness an important prevention strategy. However, little is known about where someone goes for help when they first become homeless and how well those sites are prepared to address the multitude of issues facing a homeless person. In order to address this question, we conducted a cross-sectional community-based survey in two US cities in 1997 using population proportionate sampling of homeless persons identified at 91 sites to identify ‘first-stop’ access sites and reasons for seeking help at those sites. A total of 230 persons participated in the face-to-face interview (93% response rate). From a list of 20 possible ‘first-stop’ sites, 105 (45.7%) reported going to a soup kitchen, 71 (30.9%) went to a welfare office, 64 (27.8%) sought admission to a detoxification centre, 60 (26.1%) met with a homeless outreach team, 57 (24.8%) went to a family member, and 54 (23.5%) went to an emergency room. Individuals with a chronic medical or mental health condition were significantly more likely to access a healthcare site (medical: 62.6% vs. 47.6%, P = 0.02; mental health: 62.4% vs. 38.8%, P < 0.01) or social service agency (medical: 64.0% vs. 43.3%, P = 0.02; mental health: 59.1% vs. 40.7%, P < 0.01). Those persons reporting a need for alcohol treatment were significantly more likely to first go to a healthcare site (46.4% vs. 29.1%, P < 0.01) and those with alcohol abuse/dependence were less likely to seek help from family or friends (66.7% vs. 81.9%, P < 0.01). Most respondents sought assistance for concerns directly associated with an immediate need as opposed to seeking care for issues causing their actual homelessness. These findings suggest the need to expand and integrate the availability of services at ‘first-stop’ access sites that facilitate early exits from homelessness.

Much of our understanding of substance abuse and homelessness comes from data from the 1980s and may not necessarily reflect issues or trends prevalent during the 1990s. We report data from a two-city, community-based, populations-proportionate sample of 531 randomly selected homeless adults; the study was conducted in 1997 and compared substance-abusing to non-substance-abusing respondents. Most (78.3%) met criteria for substance abuse/dependence and were abusing either cocaine or alcohol and cocaine (68.5%). In the multiple logistic regression model, male gender (odds ratio [OR] 2.94, 95% confidence interval [CI] 1.70–5.09), less than a 12th grade education (OR 1.96, 95% CI 1.11–3.46), bustling or stealing for sustenance (OR 3.14, 95% CI 1.15–8.55), and identifying a need to learn how to manage one’s money (OR 2.41, 95% CI 1.45–3.98) were independently associated with substance abuse/dependence. Drug abuse/dependence and polysubstance use among urban homeless persons became a more prevalent issue in the late 1990s. These individuals have unique needs that will require tailored interventions.

Objectives. We identified substance use patterns and factors associated with increased substance use after users become homeless. Methods. We carried out a 2-city, community-based survey that used population-proportionate sampling of 91 sites with random selection at each site. Results. Five hundred thirty-one adults were interviewed; 78.3% of them met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for substance abuse or dependence. Most of those who met the criteria reported using drugs and alcohol less since they became homeless, commonly because they were in recovery. Factors independently associated with increased use were no health insurance (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.02, 2.58), alcohol abuse or dependence (OR = 3.5; 95% CI = 1.85, 6.78), and selling plasma (OR = 2.6; 95% CI = 1.32, 5.14) or panhandling (OR = 3.0; 95% CI = 1.65, 5.55) to acquire drugs. Conclusions. Becoming homeless plays a role in self-reported substance use. Multiservice treatment programs and tailored interventions for homeless persons are needed.

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/ partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P

History and laboratory evaluations are common for patients entering substance abuse detoxification programs. We sought to identify if patient history and laboratory characteristics entering a detoxification program were associated with unsuccessful detoxification.Retrospective cohort study of 186 patients of a residential-inpatient short-term medical detoxification facility. Unsuccessful detoxification was defined as leaving for urgent medical referral or against program advice.Patients were predominantly male, middle-aged, minority, unemployed, and poly-substance users. Twenty-four patients (13%) did not complete the detoxification program (4 left for urgent medical referral, 20 left against program advice). Unsuccessful detoxification was associated with nausea and/or vomiting (p = 0.032), Caucasian race (p = 0.002), and opiates as a drug of choice (p = 0.018). Laboratory abnormalities were common but none were associated with unsuccessful detoxification.For patients admitted to a medically monitored detoxification facility, few patient characteristics were associated with detoxification outcome. Routine admission laboratories without clinical correlation may be unwarranted.

The longer a person is homeless, the more likely he or she is to experience poor health and be placed at higher risk for premature death. This makes interventions early in one's homelessness an important prevention strategy. However, little is known about where someone goes for help when they first become homeless and how well those sites are prepared to address the multitude of issues facing a homeless person. In order to address this question, we conducted a cross-sectional community-based survey in two US cities in 1997 using population proportionate sampling of homeless persons identified at 91 sites to identify 'first-stop' access sites and reasons for seeking help at those sites. A total of 230 persons participated in the face-to-face interview (93% response rate). From a list of 20 possible 'first-stop' sites, 105 (45.7%) reported going to a soup kitchen, 71 (30.9%) went to a welfare office, 64 (27.8%) sought admission to a detoxification centre, 60 (26.1%) met with a homeless outreach team, 57 (24.8%) went to a family member, and 54 (23.5%) went to an emergency room. Individuals with a chronic medical or mental health condition were significantly more likely to access a healthcare site (medical: 62.6% vs. 47.6%, P = 0.02; mental health: 62.4% vs. 38.8%, P0.01) or social service agency (medical: 64.0% vs. 43.3%, P = 0.02; mental health: 59.1% vs. 40.7%, P0.01). Those persons reporting a need for alcohol treatment were significantly more likely to first go to a healthcare site (46.4% vs. 29.1%, P0.01) and those with alcohol abuse/dependence were less likely to seek help from family or friends (66.7% vs. 81.9%, P0.01). Most respondents sought assistance for concerns directly associated with an immediate need as opposed to seeking care for issues causing their actual homelessness. These findings suggest the need to expand and integrate the availability of services at 'first-stop' access sites that facilitate early exits from homelessness.

It is important to understand the needs of those veterans who are homeless. We describe characteristics of homeless male veterans and factors associated with needing VA benefits from a two-city, community survey of 531 homeless adults. Overall, 425 were male, of whom 127 were veterans (29.9%). Significantly more veterans had a chronic medical condition and two or more mental health conditions. Only 35.1% identified a community clinic for care compared with 66.8% of non-veterans (P < .01); 47.7% identified a shelter-based clinic and 59.1% reported needing VA benefits. Those reporting this need were less likely to report a medical comorbidity (58.7% vs 76.9%; P = .04), although 66.7% had a mental health comorbidity and 82.7% met Diagnosic Screening Manual (DSM)-IIIR criteria for substance abuse/dependence. They were also significantly more likely to access shelter clinics compared with veterans without this need. Homeless veterans continue to have substantial health issues. Active outreach is needed for those lacking access to VA services.

Why, where, and when someone accesses health services have broad implications for public health and health systems management. The health care patterns of urban homeless adults and other low-income population groups are of particular concern given their high rate of use of acute care services, the conversion of many medical assistance programs to managed care, and the impact of the social environment on disease presentations. Determining which factors contribute to a person's decision to seek care at a given site can be useful in efforts to redirect nonacute services away from emergency departments and promote utilization of primary care and preventive services. The previous literature has typically focused on overall utilization patterns and barriers to care, or site-specific utilization patterns of persons seeking health care. In a community-based survey of urban homeless and housed poor adults, the 6-month health service utilization rate was 62.7%.1 Those persons residing in emergency shelters and transitional housing units had higher rates than those doubled-up with a family or friends or renting or owning their dwelling.1 This study also found health service utilization associated with white race, having one or more comorbid conditions, having health insurance, and having higher levels of social support. In a study of homeless veterans entering a domiciliary program in Los Angeles, 67% were noted to have had at least one outpatient appointment in the previous 6 months, with health service utilization associated with residential stability and usual sleeping place, health insurance, and education level.2 In a study of homeless and housed poor families in Los Angeles, the majority in both groups reported having a regular provider for preventive and illness-related care. However, more than half reported at least one barrier to seeking care. Lack of transportation, high cost, not knowing where to go, and waiting too long for an appointment were all cited as barriers.3 Difficulty meeting sustenance needs was a factor in determining discretionary care cited in a community-based survey of homeless adults encountered in public enclaves in Los Angeles.4 For many homeless persons, the emergency department is the primary source of regular care 3,5; however, it is unclear whether this is by default when no other care is available or is due to other identifiable factors. A study of New York homeless adults residing in an emergency shelter found that 27.2% had gone to an emergency department in the preceding 6 months. Utilization in this study was significantly associated with comorbid mental health and substance abuse conditions.6 Homeless adults identified through a medical record review were admitted 5 times more often to acute care hospitals and 100 times more often to psychiatric hospitals than the general population.7 In a survey of emergency department users at one large urban center, factors associated with selecting the emergency department as the source of usual care included family income less than $30,000, having been refused care in an office or clinic in the past, not having a chronic illness, and the impression that the emergency department visit cost is equal to or less than an office visit.8 Less is known about regular sources of care and factors that contribute to identifying care sites. In a survey of homeless and near-homeless adults in Los Angeles, 57% reported a source of usual care, with 55% identifying a hospital outpatient or community clinic and 23% identifying an emergency department. Having a regular source of care was dependent on several factors including age, race, gender, competing needs, long-term homelessness, and social isolation.9 However, these data are limited to one city (Los Angeles) and may not be generalizable to other cities or regions with different outreach, delivery systems, and public insurance programs. We report our findings from a community-based survey of urban homeless and housed poor adults in Pittsburgh, Pa, and describe factors associated with having a specific site of usual care and factors specific to selecting the emergency department for medical care.

The objective of this study was to describe health services utilization by homeless and housed poor adults stratified by six-month primary sheltering arrangements. The primary method used in this study was a cross-sectional survey of 373 homeless adults. Interviews at twenty-four community-based sites (in Allegheny County, Pennsylvania) assessed demographic and clinical characteristics, reasons for homelessness, functional status and social support networks, and health services utilization during the previous six months. Multivariate logistic regression analysis identified factors independently associated with health services utilization. Subjects were classified as unsheltered, emergency-sheltered, bridge-housed, doubled-up, and housed-poor. The median age of the subjects was 38.4 years; 78.6 percent were African American and 69.9 percent had health insurance. Overall, 62.7 percent reported health services use in the past six months, with significantly more use among emergency-sheltered and bridge-housed subjects than among unsheltered subjects. The study concludes that health services use among the homeless is substantial and is independently associated with sheltering arrangement, comorbid illness, race, health insurance, and social support.

OBJECTIVE: To assess the impact of two programs at the University of Pittsburgh, one that requires and one that encourages volunteer activity. In the program that requires primary care interns to spend 15 hours in a homeless clinic, we measured volunteer service after the requirement was fulfilled. In the program that encourages and provides the structure for first- and second-year medical students to volunteer, we assessed correlates of volunteering. MEASUREMENTS AND MAIN RESULTS: When primary care interns were required to spend time at homeless clinics, all (13/13) volunteered to work at the same clinic in subsequent years. Categorical interns without this requirement were less likely to volunteer (24/51; x2=12.7, p>.001). Medical students who volunteered were more likely to be first-year students, have previously volunteered in a similar setting, have positive attitudes toward caring for indigent patients, and have fewer factors that discouraged them from volunteering (p