Gaps in continuity of care: Homelessness and incarceration among Medicaid psychiatric patients

Objective: Examine risk and identified potential gaps in continuity of care for homelessness and incarceration among psychiatric patients in ten states. Method: 4,866 psychiatrists in ten states were randomly selected from the AMA Physician Masterfile; 61% responded; 34% met study eligibility criteria and reported clinically detailed data on 1,625 systematically-selected patients. Multivariate logistic regression models examined odds of homelessness and incarceration controlling for sociodemographic and clinical characteristics. Results: Overall rates were 11.6% for homelessness (SE=1.3%) and 13.4 % for incarceration (SE=1.3%), with higher rates among males, non-whites, and young adults 18-30 years. Patients diagnosed with substance use (43% homeless, 38% incarcerated), alcohol use (36% homeless, 25% incarcerated), and schizophrenia (24% homeless, 22% incarcerated) disorders were at considerable risk. One-third of public and private inpatients experienced homelessness; one-third of public inpatients experienced incarceration; nearly 1 in 5 experienced both. One-quarter of patients with emergency department (ED) visits also experienced homelessness or incarceration. Patients with severe substance abuse symptoms, ED visits, or who were treated in the public sector had 2.0 (95% CI 1.3-3.1) to 6.1 (95% CI 2.1-17.9) increased likelihood of homelessness or incarceration. Patients who discontinued their medication had 2.4 (95% CI 1.3-4.4) increased odds of homelessness or incarceration. Conclusion: The findings highlight potential gaps in the mental health treatment infrastructure for patients with substance use, psychotic disorders, and psychiatric symptom exacerbation and suggests inpatient facilities and EDs treating Medicaid psychiatric patients could play a more effective role in preventing homelessness and incarceration through improved discharge planning and care coordination.