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- Title
Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic.
- Authors
Fleming, Mark D.; Evans, Jennifer L.; Graham-Squire, Dave; Cawley, Caroline; Kanzaria, Hemal K.; Kushel, Margot B.; Raven, Maria C.
- Abstract
Key Points: Question: Was placement in a shelter-in-place (SIP) hotel during the COVID-19 pandemic associated with health system utilization among people experiencing homelessness with a history of high use of acute health services? Findings: In this cohort study of 686 high users of acute county services experiencing homelessness, those who received a SIP hotel placement had significantly fewer emergency department visits, hospital admissions, inpatient days, and psychiatric emergency department visits compared with matched controls without a placement. Meaning: These findings suggest that provision of noncongregate shelter with supportive services in SIP hotels during the COVID-19 pandemic was associated with reduced use of acute health services among people with prior high use. This cohort study evaluates the association of shelter-in-place (SIP) hotel placements during the COVID-19 pandemic with health services use among a subset of people experiencing homelessness with prior high acute health service use. Importance: Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. Objective: To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. Design, Setting, and Participants: This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. Exposures: SIP hotel placement with on-site supportive services. Main Outcomes and Measures: The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. Results: Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P <.001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P <.001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P <.001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P <.001). Conclusions and Relevance: These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.
- Subjects
CONFIDENCE intervals; MEDICAL care; RETROSPECTIVE studies; MEDICAL care use; HOTELS; DESCRIPTIVE statistics; CENTERS for Disease Control &; Prevention (U.S.); HOMELESSNESS; DATA analysis software; ODDS ratio; COVID-19 pandemic; LONGITUDINAL method
- Publication
JAMA Network Open, 2022, Vol 5, Issue 7, pe2223891
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2022.23891