Running head: PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 1

Predictors of Emergency Department Costs and Use;

and the Effectiveness of Housing First.

Anthony Crossley

James Madison University

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 2

Abstract

The present paper reviewed past research on the homeless and the impact housing interventions

may have on their use and costs of emergency services. Additionally, the paper examined how

qualitative self-reports, predictors and factors may influence emergency services. Qualitative

self-reports have shown that the homeless, shelter staff, and service providers all have concerns

with the present treatment provided for the chronically homeless found in community shelters

and medical settings. Furthermore, the paper found that the predictors and factors that were

closely associated with emergency service use were dual diagnosed homeless persons who

lacked ambulatory care. Finally, the Housing First intervention was observed to effectively

provide treatment for the homeless and to possibly reduce future reoccurrences of emergency

services. Research has supported the United States federal strategy to end homelessness; the

Opening Doors plan has been found to effectively reduce homelessness, substance abuse

comorbidity, and emergency services costs and use.

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 3

Predictors of Emergency Department Costs and Use; and the Effectiveness of Housing First

Murray Barr was a veteran, alcoholic, and homeless individual who accumulated

$1,000,000 in medical costs over ten years (Gladwell, 2006). Barr was not alone in his extreme

medical costs; one individual had a $65,000 bill after three months and another individual had

accumulated $100,000 in six months. In New York, it is estimated that $62,000,000 was spent

annually to shelter 2,500 homeless individuals; and most of that money comes from medical

costs from the emergency department (ED). Boston Health Care for The Homeless Program

tracked medical costs for 119 people over five years and found that they accounted for 18,834

ED visits; researchers estimated, on average, each visit was $1,000 (O'Connell et al., 2010).

Additionally, San Diego Medical Center reported that over the course of 18 months, 15

chronically homeless individuals were treated 417 times; researchers estimated, on average, each

persons medical cost was $100,000 (Lam & Rosenheck, 1999). The past impact of the U.S.

recession has placed current stressors on the states and taxpayers; therefore, in 2010 the U.S.

government implemented the Opening Doors plan that addressed homelessness.

In 2014, The U.S. Department of Housing and Urban Development (HUD) estimated

578,421 persons were homeless. Sixty-nine percent stayed in residential programs and 39 percent

lived on the street. The federal plan, Opening Doors, has aimed at eliminating homelessness by

implementing housing interventions. Since 2010, a 62,000-person reduction has been observed.

Additionally, over a two-year period, Affairs Supportive Housing (VASH) tenants

observed a 34 percent decrease of health costs and a 66 percent decrease in hospitalization

(Byrne, 2014); overall homelessness among veterans declined by 11 percent between 2013 and

2014 (The U.S. Department of Housing and Urban Development, 2014). Furthermore, family

homelessness and chronic homelessness had declined by three percent between 2013 and 2014.
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 4

The following paper will examine the Opening Doors effectiveness of housing

interventions in reducing ED cost and use; and additionally, will evaluate qualitative self-reports,

predictors and factors associated with ED cost and use.

Perspective of Homeless and Service Providers

McCormack et al. (2015) interviewed 20 alcohol-dependent individuals who had visited

the ED more than four times in a 12-month period. Participants were found to have definite

psychiatric diagnoses (N =11) in the anxiety, mood, and psychotic spectrums. The most common

complaint among participants was that they felt the nurses and doctors were tired of seeing

them and because of this, participants felt they received inadequate care. However, participants

would continue to go to hospitals because of the provided food, shelter, and medication. Yet

some participants reported they did not rely on the hospital for care, but were involuntarily

committed after they passed out from drinking. Regardless of the participants service care

complaints; the hospital was still preferred to shelters. Participants viewed shelters as hectic

because of their abundance of psychiatric ill residents, strict curfews, theft, and poor staff. The

participants complaints were not just isolated to their population; hospital and shelter employees

have experienced similar turmoil.

Hauff and Secor-Tuner (2014) examined issues experienced by service providers in

homeless clients. Researchers conducted 20 interviews on shelter staff and health care providers.

Shelter staff reported that many residents had chronic and communicable conditions. The

residents chronic conditions often worsen because of the lack of medical care; and

communicable conditions would frequently spread because of the dorm-style living conditions.

Staff reported diabetic residents often had the most difficulty with medical conditions. Diabetics

often had trouble regulating blood sugar because of the lack of proper nutrition, clean space and
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 5

lack of supplies. Staff also reported that many residents had limited or no forms of payments,

but frequently used ED services. In relation to McCormack et al. (2015) findings, shelter staff

reported that residents received inadequate medical care. Hospital staff reported that patients

commonly sought food and shelter; and staff would often call homeless shelters in an attempt to

accommodate those needs, however they were often denied entry because of the patients

medical needs were outside the scope of practice for the shelter. Hospital staff was obligated to

discharge medically stable patients and would frequently see and treat them again and again.

Fortunately, research has been able to identify some characteristics that contributed to ED use

and this understanding could be applied towards treatment needs.

Predictors and Factors of Emergency Department Use and Cost

Ku, Scott, Kertesz, and Pitts (2010) found that homeless patients were significantly more

likely to have been cared for by interns or residents (P =.02) and be diagnosed with psychiatric

(P <.001) or substance abuse disorders (P <.001). Researchers randomly collected patient

records between 2005 and 2006 thru the National Hospital Ambulatory Medical Care Survey

(NHAMCS-ED). In addition to the significant diagnoses of substance abuse and psychiatric

illness, researchers found that 72 out of 100 patients used at least one ED service in the past year.

These findings have been supported with previous research on how substance abuse and

psychiatric illnesses may impact ED use.

Kushel, Vittinghoff, and Haas (2002) used systematic sampling on homeless and low-

income participants; interviews were conducted over a 12-month period. Low-income was

defined as persons who rented out hotels that were cheap and were single-room-occupancy

(SRO). The participants were separated into two groups that were based on their ED use: Any

visits (N =1022) and four or more visits (N =199). In support of Ku et al. (2010), researchers
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 6

found that frequent ED visitors were significantly more likely to have alcohol or drug problems

(P =.04) and have a history of psychiatric hospitalization (P < .01). Researchers believed that

repeated ED use was encouraged because of its easy accessibility. Researchers also believed

participants used the ED because it was there only source of consistent health care; and newer

research has analyzed these financial barriers and its potential impact on ED costs and use.

Parker, Regier, Brown, and Davis (2015) examined the homeless (N =269) regarding

medical payment and costs. Researchers randomly collected demographic and medical records

between 2012 and 2013 thru the Homeless Management Information System (HMIS).

Participants were 18 years or older, and had at least one hospital visit, and utilized at least one

homeless service in the past year. Researchers found Medicaid (N =84, 31.2%) and no insurance

(N =84, 31.2%) to be the most used payment among participants. Medicare was found to be the

second used payment (N =35, 13.0%) and public funded insurance was last (N =21, 7.8%).

Forty-five participants had more than one form of payment. ED services had the highest

frequency of usage and totaled $1,128,036 in expenses between 785 visits. Inpatient services had

the most costly expense at $3,747,699 between 257 visits. Researchers noticed that ten

participants accounted for one-third of the total medical expenses; their total cost was

$1,957,469. Nine of the ten participants were covered under Medicaid or Medicare and

researchers believe it may be possible that their excessive spending could be linked to disabling

conditions. Researchers also believe it may be possible that certain federal healthcare programs

do not work well with certain homeless participants; and the need for a different approach may

be necessary because of the continued high costs and use of the ED. Past research has suggested

that medical expansions do not necessarily cause lower visits or costs, but primary care providers

(PCP) may.
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 7

Chwastiak, Tsai, & Rosenheck (2012) examined participants that had a PCP and those

who did not. Researchers collected demographic and medical records across 11 communities

(e.g., New York City, Los Angeles, Philadelphia) between 2004 and 2006 thru the Collaborative

Initiative to Help End Chronic Homelessness (CICH). Participants had to be continuously

homeless for at least one year or in the past three years had experienced four or more episodes of

homelessness. Self-reported measures and interviews were conducted on 870 persons. Overall,

participants were found to have high rates of reported mental illness (35.6%) and substance

abuse disorder (54.5%). The non-PCP group had significantly higher occurrences of ED services

(P =.001) and payment difficulties (P =.001). The PCP group had higher rates of state assistance,

which may have accounted for the observed 71.5 percent of participants reporting no payment

difficulties. Researchers also conducted regression analyses that evaluated characteristics of

participants with a PCP. Health insurance (P =.05) and poor physical health (P =.01) were

significant predictors, yet psychiatric illness was not. Psychiatric illness may not be a significant

predictor on PCP, but as previously seen in the findings of Kushel et al. (2002) and Ku et al.

(2010), may be a predictor in ED use.

DAmore, Hung, Chiang, and Goldfrank (2001) composed a 50-item questionnaire that

was used to identify demographic and psychiatric history that may lead to ED use. Researchers

found that mental illness, substance use, and social isolation were significant predictors in ED

utilization; social isolation was defined as having no social contacts. Homeless participants (N

=252) had significantly higher rates of depression (OR =13.4, 70%) and schizophrenia (OR =5.1,

27%), however, alcoholism (OR =24, 81%) and social isolation (OR =33.3, 81%) were the best

indicators for ED services. Additionally, researchers observed that a significant amount of

homeless participants did not have a PCP (P <.001); it is possible that the lack of a PCP resulted
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 8

in higher ED use. Similar rates of psychiatric illness, substance abuse, and concerns of PCP

were observed in Chwastiak et al.(2012). Furthermore, evidence has suggested that age may be

useful in identifying patient needs.

Brown and Steinman (2013) found evidence of physical and psychological differences of

medical needs between older and younger homeless adults. Researchers used the NHAMCS-ED

to gather demographic and clinical records. Adults who were 50 years or older were considered

older and adults who were 18 years or older were considered younger. Researchers found that

older adults (N =351) were significantly more likely to have Medicare (P =.001), physical

injuries (P =.02), cardiovascular complaints (P =.02), arrived by ambulance (P =.02), and have

alcohol-related injuries (P =.03). Younger adults (N =826) were significantly more likely to have

psychiatric complaints (P =.01), requests for alcohol or drug detoxification (P < .001), and were

more likely to have a psychiatric diagnosis (P =.002). Researchers believe it may be possible that

older adults have significantly more physical problems and younger adults may have

significantly more psychiatric problems.

In addition to all of the previously discussed research, German experimenters observed

psychical and psychiatric characteristics of 65 homeless participants who abused alcohol (Salize

et al., 2002). Homelessness was defined as not having reliable housing. Researchers eliminated

individuals who were accommodated by programs that provided hotel housing. The Structured

Clinical Interview DSM-IV (SCID) was used to diagnose mental and substance use disorders.

Five experienced researchers conducted the interviews: one psychiatrist and four clinical

psychologists. The psychiatrist and two clinical psychologists observed each client; procedures

and interviews lasted five to six hours per person. Interviewers recruited the participants on the

street and in homeless shelters. Researchers found that alcoholic clients had significantly higher
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 9

rates of somatic disorder. Researchers used regression methods to observe factors that influenced

participants with somatic disorders; the level of significance for the analysis was defined at .10.

Alcoholism (P =.008, OD =4.31) had the greatest potential influence on somatic disorders.

Researchers believe lowered cases of somatic disorders may be possible with the implementation

of programs that addressed addictive behavior. Research regarding the homeless and somatic

disorders appeared to be limited within the U.S. It is possible that these findings may contribute

towards a consideration of future research on the homeless and somatization disorder.

Regardless if somatization disorders played a significant role in the homeless community,

researchers observed a common theme; the homeless may have chronic health problems and

poor medical coverage. Consequently, this has resulted in higher rates of ED costs and use; and

lower rates of consistent ambulatory services. Research also suggested that physical or

psychiatric complaints and age could be related; Brown and Steinman (2013) found that older

adults had physical complaints and younger adults had psychiatric complaints. Additionally,

DAmore et al. (2001) found characteristics of depression, schizophrenia, and alcoholism among

the homeless who used the ED. Researchers also found that forms of payment could impact ED

costs and use. Parker et al. (2015) noticed that federal health insurance (e.g., Medicaid,

Medicare) might not contribute towards lower ED costs and use; or effectively provide

treatment. Research suggested that there may be a possible alternative that may lower ED costs

and use; Chwastiak et al. (2012) found that homeless individuals with a PCP had overall lower

medical costs and emergency service use.

Overall, substance abuse comorbidity may be the highest problem for ED costs and use.

Unfortunately, many patients are unable to simultaneously receive adequate and inexpensive

treatment; Opening Doors has implemented primary and behavioral health care services that may
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 10

address that barrier. Opening Doors has stated that, Housing assistance coupled with health care

has been shown to decrease overall public expense and make better use of limited resources,

such as emergency rooms and hospitals (United States Interagency Council on Homelessness,

2015, p. 49). Therefore, the federal strategic plan has implemented housing assistance programs:

Continuum of Care (e.g., Treatment First) and Pathways to Housing (e.g., Housing First). It is

possible that this combined approach of housing assistance and health care service could

decrease ED use and costs.

Housing Interventions

Dr. Sam Tsemberis founded the Pathways to Housing organization in 1992. Tsemberis

argued that previously used staircase models (e.g., Treatment First) were ineffective because of

the assumption that the homeless value independent housing when they have earned it

(Pleace, 2011). The Housing First model used Assertive Community Treatment (ACT) to

provide clients with 24 hours, seven days a week, instant access to supportive services and

independent housing (Gulcer, Stefancic, Shinn, Tsemberis, & Fischer, 2003). ACT has shown to

reduce hospitalization rates, increase tenure in community housing, and increase retention rates.

ACT teams help clients on housing issues, vocational rehabilitation, money management and

mental and substance abuse problems. Harm reduction and client choice were key operating

principles. The Housing First model did not implement an abstinence policy; participation did

not require clients to be sober or enroll in treatment (Tsemberis & Eisenberg, 2000). Instead

professionals aimed at enhancing the clients quality of life, providing employment

opportunities, and eliminating counterproductive behavior by honoring the clients resistance.

Clinicians believe that this approach may lead to better engagement and maintenance. The only

two requirements of the program are that clients are to meet with staff at least twice a month and
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 11

enroll in a money management plan. However, housing or services would not be denied to a

mistrustful person who spent many years homeless.

When clients are admitted to the Housing First program; staff will help them in locating and

selecting apartments. Available apartments are usually one-bedroom or two-bedroom units; and

the program subsidizes 70 percent of the clients rent through state and federal funding. If staff is

unable to find a suitable apartment for clients, Housing First will provide resources for a bed at a

hotel or homeless shelter (Tsemberis & Eisenberg, 2000). Overall, research has found that

clients reported higher life satisfaction, housing stability, and psychological health with the

Housing First approach.

The Continuum of Care model enforced abstinence from alcohol or drugs in a shared

housing environment (Gulcer et al., 2003). Treatment First professionals recorded and assessed

client progress before graduating them to independent housing. Treatment First models have had

difficulties in establishing trust and clients were at higher rates of withdrawing from treatment if

disparities occurred between them and the clinician. Additionally, the model has demonstrated

lower rates of housing stability and higher frequencies of relapse for dual diagnosed clients. In

the past, the majority of clinicians and researchers have advocated transitional treatment;

professionals argued that the Treatment First approach is cost-effective and clients responded

better to structured care and residential supported environments. However, more and more recent

studies have shown that the Treatment First model may cost more and be counterproductive in

progress; and because of this compelling evidence, service providers have been slowly

implementing or incorporating the Housing First model. Additionally, attempts have been made

to prove the effectiveness of Housing First to skeptics; a group of researchers conducted an

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 12

experiment around the enabling hypothesis of non-abstinence increased alcohol-related

problems.

Collins et al. (2012) conducted a quasi-experimental, within-subjects design on the

impact of the Housing First model on alcohol-dependent clients. Researchers recruited 95

chronically homeless individuals; the alcohol-dependent participants were selected because of

their significant hospital costs or through a recommendation from a community service provider.

Researchers conducted baseline interviews on the participants demographic and medical history

and follow-up interviews were conducted every three months. Researchers used a logistic

regression analysis in order to be sure that there were no significant differences present. Alcohol-

related problems were measured with a 15-item Short Inventory of Problems (SIP-2R) that was

adapted from the Inventory of Drug Use Consequences (2R). Multilevel growth models were

used to analyze possible associations between predictor and outcome variables. Researchers

found that when the Housing First intervention was introduced, on average, the participants

typical drinking pattern significantly decreased by 8 percent and an additional 3 percent each

following month. Self-reported delirium tremors significantly decreased from 65 percent to 23

percent (P <.001) and overall alcohol-dependent symptoms, on average, changed from five

symptoms to two symptoms. Researchers successfully addressed the enabling hypothesis;

Housing First does not increase problem drinking. Research also shows that Housing First may

be promising in reducing drug use behavior.

Padgett, Stanhope, Henwood, and Stefancic (2011) conducted a 12-month study that

observed the Housing First and the Treatment First models influence on homeless participants

that had substance abuse comorbidity. Researchers conducted three face-to-face interviews (e.g.,

baseline, six months, and 12 months), monthly telephone interviews, and six-month follow-up
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 13

interviews. Interviews revolved around the participants needs, service experience, social

relationships and mental health status; however, the two outcomes of interest variables were

substance use and treatment. Through the course of the study, researchers found that participants

in the Housing First group had significantly lower rates of substance use (P =.004) and lower

rates of treatment dropout (P =.001). Researchers believe that it is possible that the Housing First

model could effectively be used in transitioning mentally ill persons to leading stable lives.

Additionally, researchers believe that it is possible that the housing security that was provided

enabled the motivation to control substance use. Although the research of Padgett et al. (2011)

may have effectively addressed the impact Housing First has on substance use; researchers did

not analyze the models impact on medical costs.

Gulcer et al. (2003) conducted a study on the Continuum of Care and Housing First

model on ED visits and costs. Researchers speculated that Housing First would be more effective

than Continuum of Care in reducing ED and psychiatric hospital visitations in a 2-year period.

The prediction was influenced by past research that observed housing retention in 88 percent of

Housing First participants and 47 percent in Continuum of Care participants. Additionally,

researchers predicted participants that were previously admitted to psychiatric hospitals, would

continue to have greater rates of hospitalization when compared to participants who were not

hospitalized. Researchers made this prediction based on past studies suggesting that a positive

correlation may exist between high hospitalization rates and previous hospitalization.

Researchers also took into consideration the costs associated with the models. Furthermore, past

research found that the overall Housing First costs were significantly less than leaving someone

homeless2.5% of the total cost. To further elaborate on the cost effectiveness, Pleace (2011)

found that Housing First would potentially save the taxpayer money. Participants are less likely
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 14

to be arrested and use emergency shelters and ED services. With all past considerations, Gulcer

et al. (2003) implemented a quasi-experimental design on Continuum of Care (N =126) and

Housing First (N =99) . The uneven assignment ratio reflected the expectation that attrition may

result in the Continuum of Care control group. The clients involved in the conditions had to meet

three participant characteristics: (1) mental illness, (2) six months of housing instability, and (3)

experienced homelessness in the past 30 days. Participants were randomly assigned to a group

that had two levels: (1) Participants recruited from the street and (2) participants recruited from

hospitals. Researchers conducted statistical analyses to be sure baseline demographics were not

significantly different. In person-interviews were conducted every six months along with

monthly telephone calls; the follow-up rate was 93% over the 24 month-period. Researchers

found that participants of the experimental group had significantly lower rates of hospitalization

(P <.01). A post-hoc comparison found that hospital participants had the greatest decline in

hospitalization rate, but had continued to have higher medical expenses (P <.001) than street

participants. The Housing First and Continuum of Care models both displayed effectiveness in

decreasing medical expenses and hospitalization; however, the Housing First condition observed

greater significance in both hospital and street participants. Researchers believe that it is possible

that the structure of Housing First was effective because of the independent housing, support

systems, and removal of stringent treatment plans.

In addition to the previously discussed research, Pleace (2011) conducted a literature

review on Housing First models. Several longitudinal studies had shown that the model had

produced significantly better housing sustainment, resettlement outcomes, and fewer costs than

staircase models; it is possible that these effects were observed because participants made less

use of the ED.

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 15

Discussion

Opening Doors has sufficiently addressed many of the associated factors that are related

to homelessness by implementing Housing First interventions. McCormack et al. (2015)

observed that many alcohol-dependent individuals reported abusing hospital benefits, receiving

inadequate care and repeatedly visiting the ED. Parker et al. (2015) observed the medical costs

that were associated with the homeless; ED services had the greatest frequency of usage and

inpatient services had the highest costs of usage. Researchers also noticed that federal medical

insurance or lack of insurance, failed to lower ED costs or use. However, Chwastiak at al. (2012)

observed that PCPs may potentially lower ED costs and use, more so than federal medical

insurance. Housing first has effectively addressed these concerns by providing ambulatory health

services that emphasize choice and control; and the approach has shown decreased rates of

hospitalization and medical costs (Gulcer et al., 2003; Pleace, 2011).

Additionally, substance abuse comorbidity may contribute to frequent ED visits (Brown

& Steinman, 2013; Chwastiak, Tsai, & Rosenheck, 2012; DAmore et al., 2010; Ku et al., 2010;

Kushel et al., 2002). Housing First addressed substance abuse comorbidity by providing flexible

recovery plans, harm reduction education, and treatment accountability (Pleace, 2011).

Researchers observed the effectiveness that Housing First had on substance abusers by finding

lower rates of drug use and treatment dropout (Collins et al., 2012; Padgett et al., 2011). I believe

that the Opening Doors approach on homelessness is effective; however, I believe the plan

should reject their current use of Treatment First models.

The U.S. research on the homeless and somatization disorder seem to be almost non-

existent. Foreign researchers have suggested that substance abuse comorbidity may significantly

contribute towards ED costs and use. German researchers observed alcohol-dependent

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 16

participants to have significant somatic signs and symptoms. It is possible that somatization

disorder many contribute to ED within the U.S and my internship at a homeless shelter may

support that prediction.

Somatic signs and symptoms were observed in a 20-year old resident at the Salvation

Army homeless shelter. John would frequently complain of abdominal pain and constipation.

John habitually visited IBS specialists, proctologists, physicians, and psychiatrists. The majority

of Johns treatment revolved around ED services and a Salvation Army staff speculated that he

had a totaled hospital bill of $80,000 dollars over a six-month period. Eventually, medical

professionals diagnosed John with somatization disorder and over time his excessive ED services

declined. Despite the somatization diagnosis, staff observed multiple occasions where Johns

mother, Jane, imposed concerns that his ailment was in fact real. Jane would not only accompany

John to appointments and ED visits, but would also influence his social life (e.g., friends, job).

After John and Janes repeated and involuntarily disclosures from the medical community and

their codependency observed at the shelter; the staff implemented a limited contact policy

between the two. It may be possible that Jane suffers from factitious disorder. Shelter staff had

also noticed similar trends; specifically conveniently injured children and their mothers

suggested ED use to treat them. One case involved shelter resident, Cindy. She consistently took

her child to the ED for oddly placed abrasions and bruises (e.g., back, shoulder, feet). Eventually,

staff decided to evict her and call social services because of the possibility of child abuse.

In addition to physical and psychiatric conditions that are possible predictors for ED use,

I believe future research needs to be conducted on somatization and factitious disorders among

the homeless population. Currently, there is very limited U.S. research on somatization and
PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 17

factitious disorders in relation to the homeless population. It may be possible that the disorders

unknowingly contribute to ED uses and costs.

In closing, the U.S has made a profound impact on the homeless community. Opening

Doors has not only provided effective and humanitarian treatment plans, but also delivers

reduced rates of homelessness and lower costs. The success of Opening Doors has been difficult

for the GOP to deny; therefore, increased funding will continue thru 2016. The U.S budget will

provide an increase of, 67,000 new Housing Choice Vouchers to support low-income

households, including families experiencing homelessness (United States Office of

Management and Budget, 2015, p. 43). Additionally, the budget included a 7.8 percent increase

for the Department of Veterans Affairs (VA) that would benefit homeless veterans. I believe the

increased funding will continue to make great strides towards ending homelessness; however, it

may not reduce the stigma that it carries. Perhaps future research should investigate how young

students respond to sociocultural classes that address such issues.

PREDICTORS OF EMERGENCY DEPARTMENT COSTS AND USE 18

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