Preferences for sites of care among urban homeless and housed poor adults.

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.