The Health Impact of Supportive Housing for HIV-Positive
Homeless Patients: A Randomized Controlled Trial
David R. Buchanan, MD, Romina Kee, MD, MPH, Laura S. Sadowski, MD, MPH, and Diana Garcia, MPH
June 2009, Vol 99, No. 6 | American Journal of Public Health
The latest version is at Published Ahead of Print on April 16, 2009, as 10.2105/AJPH.2008.137810
Objectives. We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV.
Methods. HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count > 200 and viral load < 100 000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts.
Results. Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts.
Conclusions. Homelessness is a strong predictor of poor health outcomes and
complicates the medical management of HIV. This housing intervention im-
proved the health of HIV-positive homeless people. (Am J Public Health. 2009;99:
The full article is available at: http://www.ajph.org/cgi/reprint/96/7/1278
Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults
A Randomized Trial
Laura S. Sadowski, MD, MPH; Romina A. Kee, MD, MPH; Tyler J. VanderWeele, PhD; David Buchanan, MD, MS
Context Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services.
Objective To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses.
Design, Setting, and Participants Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat.
Intervention Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers.
Main Outcome Measures Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors.
Results The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], -1.2 to 0.2), 2.7 fewer hospital days (95% CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, -2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%).
Conclusion After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care.
The full text of the article is available at: http://jama.ama-assn.org/cgi/content/full/301/17/1771#AUTHINFO