Housing First and Emergency Medical Services

As we begin the new year, we are excited to launch our new blog series: Medical Research on Health and Housing. This series will analyze and summarize current medical literature exploring the multiple links between health and housing. For our first post, Andy Hyatt and Andrew Olsen, medical students at Boston University School of Medicine, have worked with MHSA Advisory Council Member Dan Dworkis, MD-PhD, to analyze research about the connection between Housing First and reduced use of emergency medical services.

PAPER: Housing First Is Associated with Reduced Use of Emergency Medical Services

CITATION: Mackelprang, J., Collins, S., & Clifasefi, S. (2014). Housing First Is Associated with Reduced Use of Emergency Medical Services. Prehospital Emergency Care Prehosp Emerg Care, 476482.

SUMMARY: Mackelprang and her colleagues enrolled 91 chronically homeless adults with severe alcohol problems who had recently moved into a single-site Housing First program in Seattle. They interviewed their study participants at three-month intervals for a follow-up period of two years. They also obtained administrative data on publicly funded resource utilization from two years prior to, and subsequent to, the participants' placement in the Housing First program. Using this data, they compared use of emergency medical services (EMS) in the “before housing” period to EMS contacts in the “after housing” period to see how access to low-barrier housing and supportive services affected participants’ EMS utilization.

Participants in housing had 54% fewer contacts with emergency services compared to before they had housing, from about 16 EMS contacts per month to about 10 EMS contacts per month. Moreover, housing had a cumulative association with EMS use over two years: during the first two years spent in a Housing First program, the study participants were 3% less likely to use emergency services for each month they were housed.

WHAT THIS MEANS: The findings support the view that enrollment in a Housing First program helped reduce utilization of emergency medical services among chronically homeless adults with severe alcohol problems.

ADVOCACY: Emergency medical services are an inefficient and costly way to care for vulnerable patients with chronic medical conditions, such as homeless individuals struggling with alcoholism. Health care funders like state Medicaid programs thus have both a public health and a financial incentive to reduce EMS utilization by high-need populations. Given this, housing service providers can advocate that increased funding for Housing First will be at least partially offset by reductions in Medicaid expenditures for EMS, which are often paid on a “fee-for-service” basis.

Further opportunities will likely arise for housing providers to work with managed care organizations (MCOs) as well as less traditional health care payers like accountable care organizations (ACOs), both of which have more incentives to control costs and some greater flexibility in spending money on non-medical services.

Medicaid expansion and reform under the Affordable Care Act provides opportunities for Medicaid to fund some Housing First services. Evidence that Housing First can decrease utilization of expensive emergency services among expensive “high-utilizing” patients can help housing organizations make a business case for increased funding for housing interventions to state governments to MCOs/ACOs, as their investment in housing could yield returns in decreased EMS costs.

About the Authors

Andy Hyatt is a second year medical student at the Boston University School of Medicine. Among many other things, he is one of the student leaders of the Homeless Health Immersion Experience, a service learning group placing students at Boston Health Care for the Homeless Program, and is a student board member of the BU Advocacy Training Program. He hopes to devote his career to using housing and the social determinants of health to address health care inequality.

Andrew Olsen also studies at Boston University School of Medicine. He is an advocate for health justice, a member of BUSM’s Outreach Van Project and Community Health Project, and a musician. He hopes to leverage his training to expand opportunities, reform health policies and improve care for the poor.

Dan Dworkis, MD-PhD, is a senior resident in emergency medicine in the Department of Emergency Medicine at Harvard Medical School and the founder of The Lever Institute, which builds theory and tools to help develop ERs into fulcrums for positive change in the communities they serve.

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