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Investigation of Racial and Ethnic Disparities in Service Utilization Among Homeless Adults With Severe Mental Illnesses

Dr. Horvitz-Lennon is affiliated with the Department of Psychiatry, University of Pittsburgh, 201 North Craig St., Pittsburgh, PA 15213 (e-mail: horvitzlennonmv{at}upmc.edu), where Mr. Baik is with the Department of Statistics. Dr. Frank and Dr. Normand are with Health Care Policy, Harvard Medical School, Cambridge, Massachusetts, and Dr. Alegría is with the Department of Psychiatry, Harvard University. Dr. Normand is also with the Harvard School of Public Health. Dr. Thompson is with the Department of Psychiatry, University of California, San Diego. Dr. Rosenheck is with Yale University, New Haven, Connecticut, and the Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut. This article was presented in part at the annual meetings of the Academy of Health (poster), June 4, 2007, Miami, Florida, and of the American Public Health Association (oral presentation), November 7, 2007, Washington, D.C.

OBJECTIVE: This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. METHODS: Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. RESULTS: The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities. CONCLUSIONS: Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed.

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