Journal of Health Care for the Poor and Underserved

Brief communication HEALTH CARE NEEDS AND SERVICES UTILIZATION AMONG SHELTERED AND UNSHELTERED MICHIGAN HOMELESS Substantial literature and clinical experience has drawn the association between homelessness and elevated medical need.1"5 Since the mid-1980s, many programs from both private and public sources have provided health care for the homeless, usually in urban settings. Few would claim, however, that such efforts have been sufficient to provide more than a small fraction of medical care that is needed. Given that resources to provide primary health care services and outreach to the homeless are becoming more difficult to secure and that the size of the homeless population is not expected to diminish, the most efficient methods of serving this high-risk group should be designed with regard to the greatest unmet needs. Unmet need, however, is difficult and expensive to measure directly without substantial clinical data. Qn the other hand, indirect measurement of unmet medical need may be a more suitable approach in a resource-poor environment. Also, inferences of unmet need can be obtained by analysis of medical care utilization by different risk groups among the larger homeless population. Under the assumption that primary care utilization tends to reduce the need for emergency room use and hospitalization, it would be expected that subgroups of the homeless that utilize relatively few primary care services would also experience more hospitalizations or emergency room services. Wright and Weber2 indicated that many of the emergency room visits by homeless persons in their study were initiated for medical problems that could have been taken care of in a primary care setting, if the individuals had been able to obtain routine health care services. Other investigators have consistently discussed the substitution of emergency room visits for routine and consistent medical care by homeless persons who do not benefit from public medical insurance.6"9 Subgroups using more of these latter categories of care would be characterized as having greater relative unmet medical need than those whose principal medical care utilization is based on consistent clinical or primary care services. Access to care has been recognized as one of the fundamental challenges to homeless adults since the onset of the modern recognition of the problem in the early 1980s. The Robert Wood Johnson Foundation and many other mainstream sources of influence and research have focused their efforts on the issue of access to care. Barriers to access that have been investigated for homeless populations have usually included the lack of financial means of utilization; Journal cf Health Care far the Poor and Underserved · Vol. 10,No. 1 · 1999 6 Health Care Among Michigan Homeless physical make-up of a clinic or hospital that impede access, such as building design; hours of operation; waiting time for treatment upon arrival at a clinic or hospital; personal difficulties with time-orientation; frustration or anxiety thresholds and an individual's capacity to deal with bureaucracies; and transportation to a treatment facility.10"12 Barriers to substance abuse treatment access have also been specifically investigated for homeless adults.13 This article presents a comparative analysis of sheltered and unsheltered subsets of homeless adult populations in Michigan based on two field surveys between 1992 and 1994. The purpose of the surveys was to determine whether measurable differences could be detected regarding medical care utilization and, by inference, unmet medical needs. An analysis of the role of transportation services to health care settings is included within a discussion of the comparative access to care of these two subsets of the homeless population. The differences in the purposes and sample designs of the two studies provided the basis for a comparison of sheltered versus unsheltered adult homeless individuals. Unlike most investigations of the homeless, the majority of the respondents in both of these samples were provided with some form of health insurance at the time of the interview. Fewer than 30 percent of both men and women who were in a shelter had no health insurance, and 100 percent of the unsheltered sample were covered by a special managed care program for the medically indigent. Kreider and Nicholson indicated that eliminating financial barriers, alone, may not increase the health care utilization of homeless populations.10 The...