• Laura S Sadowski, Romina A Kee, Tyler J VanderWeele, and David Buchanan.
• Collaborative Research Unit, Department of Medicine, Stroger Hospital of Cook County, 1900 W Polk St, Room 1606, Chicago, IL 60612, USA. sadowski@cchil.org
• JAMA. 2009 May 6; 301 (17): 177117781771-8.

ContextHomeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services.ObjectiveTo 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 ParticipantsRandomized 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.InterventionHousing 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 MeasuresHospitalizations, 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.ResultsThe 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%).ConclusionAfter 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.Trial Registrationclinicaltrials.gov Identifier: NCT00490581.

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