NYU STUDY FINDS THAT FAMILIES WHO WERE HOMELESS ARE NOT BEING WELL-INTEGRATED INTO THE HEALTH CARE SYSTEM AFTER THEY FIND STABLE HOUSING Less than one-quarter of formerly homeless families rely on private doctors or HMOs for health care after leaving the shelter system New York University researchers, following homeless and poor New York City families for five years, found that upon leaving shelter, families are not being well integrated into primary care services. The study found that a majority of previously homeless families do not make the transition to private physicians or HMO’s but instead maintain a greater reliance on emergency departments and hospitals or have no regular source of care. Compared to poor families who were never homeless, previously homeless families are twice as likely not to have a primary care physician or HMO and three times as likely to rely on emergency rooms or have no regular source of care.

The study shows that a history of residential instability, particularly past shelter use, strongly predicts where poor mothers currently seek health care. The key finding is that a history of any shelter use, regardless of the length of time in shelter, greatly increases the odds of poor mothers using emergency departments or not having a regular source of care over using private doctors or HMOs as a regular source of care.

The study’s findings will be published in the December issue of Medical Care. The authors are Lisa M. Duchon, Ph.D., a graduate of the NYU’s Robert F. Wagner Graduate School of Public Service and now at the Commonwealth Fund, professor Beth C. Weitzman of NYU’s Wagner School and NYU psychology professor Marybeth Shinn.

Dr. Duchon said, “Our study is the first to look at families after they have left the shelter system and made the transition to stable housing. We found that many formerly homeless families look similar to families still living in shelter in terms of their higher rates of using emergency departments for primary care and not having a regular source of care, compared to poor mothers who were never homeless. Few providers seem aware of this missed opportunity to improve health care access for mothers in their transition from shelter to permanent housing. The over-reliance on emergency departments translates into substantial economic and medical disadvantages. The emergency department is a costly place to provide non-emergency care, and it is not a place families can depend on for the preventive and follow up care they need.”

Professor Weitzman said, “For years, government and private foundations have operated under the assumption that as soon as homeless families find stable housing, they are taken care of. Most services that provide support to homeless families don’t pay enough attention to the transitional period immediately after homelessness. The families simply fall off the radar screen. Improving access to health care for families who leave the shelter system is just as important as mitigating health care barriers for those living in shelter.”

As noted by Professor Shinn, “It is possible that the shelter stay and frequent moves may have disrupted existing attachments to providers, and renewing those relationships may prove difficult. The stigma of past homelessness may also make it difficult for families to connect with private physicians and HMOs. The findings also raise questions about whether specialized services, which are often provided on-site to homeless families, may disrupt their ties to private physicians or HMOs, too.”

According to Dr. Duchon, “With the growth of Medicaid managed care, linking families, as they leave shelter, to appropriate managed care plans, may reduce reliance on emergency departments, and better ensure access to preventive care. Community-based managed care providers may be particularly well-suited to improve access for formerly homeless families. With a majority of the poor mothers in the study relying on providers other than private doctors or HMOs, safety net providers are crucial to providing health care access to poor families. This may be even more true as commercial health plans have begun retreating from Medicaid managed care and more poor mothers, many of whom have significant health problems, are leaving welfare for jobs without health insurance, only to lose their Medicaid coverage.”

Researchers conducted interviews with 543 poor mothers in New York City, once in 1988, and again beginning in 1992. The sample included 251 mothers who first entered shelter after their 1988 interview, and 292 mothers who spent no time in shelter before or after that point. Mothers were asked about the source and volume of medical care used in the prior year.

The main findings of the NYU study are as follows:

· Previously sheltered mothers had a greater reliance on emergency departments and weaker ties to private physicians/HMOs, compared to mothers who never used shelter.

· Only 23% of formerly homeless mothers used a private doctor or HMO as their usual source of care, compared to 53% of poor mothers who were never homeless.

· Almost three times as many previously sheltered mothers used emergency departments or had no regular source of care compared to mothers who never used shelter (21% vs. 8%).

· About one third of formerly homeless and never homeless mothers used a hospital outpatient department as a regular source of care (32% vs. 27%).

· Previously sheltered mothers were twice as likely as mothers who never used shelter to rely on community or public health clinics as a usual source of care (23% vs. 11%).

· Living in one’s own apartment for a year or more—defined as being residentially stable—was associated with reduced odds of using an emergency department or having no regular source of care.

The Medical Care article is the product of an ongoing research project at New York University on poor and homeless families in New York City. This project has been funded principally by a grant from the National Institute of Mental Health and by a contract from the New York City Human Resources Administration.

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