Frequent Users of Health Services

Some people experiencing homelessness are frequent users of costly inpatient and emergency health services. Repeated use of crisis and inpatient health services is extremely costly, but can be avoidable. “Frequent User” programs and partnerships use health service utilization data to identify the most frequent users of health services and engage them in more appropriate and cost-effective services, including primary and preventive health care, treatment services, social services and supports, and connections to stable housing. (Similar programs also exist for individuals with frequent interaction with the criminal justice system). When care management and flexible services linked to stable housing are provided to “frequent users” who are experiencing homelessness the results include housing stability, significant reductions in the utilization and costs of emergency health services, and better treatment for complex health issues.

Problem or Challenge:

A large share of health care costs are borne by a small group of patients with extraordinarily high costs, and a disproportionate share of these high-cost patients are experiencing homelessness. It is practically impossible for people with complex health problems experiencing homelessness to access the health care and treatment services they need, or to follow through on the advice of health care providers.  People experiencing homelessness may receive care in hospital emergency rooms or during an inpatient hospital stay, but after they are released from the hospital they often do not receive ongoing comprehensive primary care and behavioral health services that would help to better manage health risks and chronic conditions and prevent recurring crises.  Inability to manage medical conditions makes repeated health crises more likely.  Vulnerable people can get caught in a cycle that includes emergency rooms, detox or sobering centers, ambulances, jails, shelters, and the streets. This “institutional cycle” is both tragic and extremely expensive. By focusing on the most frequent and costly users of health care services, Frequent User programs can reduce costs while also improving outcomes for people with complex needs.


Frequent User programs work by identifying patients with a history of costly utilization of emergency services who are experiencing homelessness and connecting them to stable housing and cost-effective, community-based health care and support services.  Frequent User programs use administrative data to target clients, engage those clients to enroll in the program and offering linkages to housing using a Housing First approach and patient-centered health services, and use data to demonstrate outcomes.

Data analysis to identify the most frequent users of costly health services

Data analysis of health service utilization data including hospital billing records is used to identify frequent, costly users of emergency health care services. Data analysis may be conducted by a hospital or public agency, often working in partnership with a researcher or in-house data analysts.  Funding from a foundation is often used to support data analysis and planning. Hospital records and/or claims data (from Medicaid or similar programs that provide health insurance to people with extremely low incomes) are used to identify patients who have multiple emergency room visits or inpatient hospital stays during a period of a year or more. When possible, looking at data for at least two years can distinguish the small group of individuals whose patterns of service use are sustained over time and unlikely to change without some intervention from people experiencing a temporary acute medical crisis. Hospital records and billing information are generally not sufficient to identify which patients are experiencing homelessness.  Sometimes homeless patients can be identified by checking for shelter addresses, or the hospital may use a special zip code or other data element to indicate that a patient is homeless when he or she enters the hospital.  With the proper data sharing agreements, communities can link hospital records with data in a Homeless Management Information System (HMIS) to identify persons experiencing homelessness who are also frequent users of hospital inpatient and emergency room care. 

Some frequent user programs use data analysis to create a list of frequent users to participate in the program.  This list may be shared with outreach workers who try to find people in shelters or other community settings and seek to engage them in services, or the hospital may create a system to flag patient records and contact an outreach worker when the person returns to the hospital again for care.

Even when the data matches produce information that does not identify individuals by name, the analysis can help to guide planning and implementation of programs by describing the characteristics of people who are both homeless and the most frequent users of crisis health services.  This type of analysis can be used to create tools (predictive algorithms) that can predict which people are most likely to have the most high-cost and avoidable emergency room visits and inpatient hospitalizations.  One example is a screening / triage tool that has been developed by the Economic Roundtable to identify vulnerable homeless adults who are likely to have patterns of service utilization that would put them in the top decile (10 percent) of the distribution of costs among all homeless people. 

Outreach and Engagement Strategies

Engaging and enrolling clients into frequent user programs requires collaboration between people working inside emergency departments and hospital discharge planners, and people working outside of the hospital to provide care and ongoing support in community settings.  Collaboration and ongoing communication between hospital staff and community service providers is crucial to the success of efforts to identify, locate, and engage frequent users and understand their most critical needs.  It is important to have clear communication about the program’s target population and eligibility criteria, and the services and supports available from the program. This communication encourages appropriate referrals and will help establish credibility about the program’s capacity to follow through and deliver an effective response. 

When hospitals, health systems, or public insurance programs provide lists of frequent users, finding and engaging these individuals can be very challenging and time consuming, particularly if the lists and contact information are not up to date. Partnerships with hospitals can support the implementation of a system to flag a person’s medical record so that an outreach worker can be notified when the person comes to the emergency room or is admitted to the hospital. The outreach worker can meet with the person in the hospital  to establish a connection and make plans to follow up with additional support.  Since emergency room visits often occur at night or on weekends, it is also important to have a strategy for providing a timely response to referrals from hospitals if an outreach worker is not available when contacted.

Persistent efforts may be required, using a non-threatening and non-judgmental approach, to establish trust and overcome barriers resulting from isolation, past experiences with coercive or insensitive care providers, and symptoms of mental health and/or substance use problems.  Frequent, face-to=face interactions are often needed to create a trusting relationship and assess the client’s needs and strengths. Outreach workers may offer small incentives or practical support, including a meal, warm clothing, or a gift card to help with immediate needs and to build a relationship that can lead a client to accept other services, including more appropriate health care and treatment..

Housing First

Housing is a stabilizing factor that facilitates appropriate management of chronic health and behavioral health conditions and access to and engagement in appropriate care. Housing also contributes to a reduction in risks that contribute to avoidable health crises. Housing First strategies, which remove barriers and facilitate access to housing opportunities, and make available ongoing supports to help people achieve housing stability, are important because people who are the most frequent users of inpatient and crisis health services are often unable to meet the requirements of other types of programs that may require people to demonstrate “housing readiness”.

Creating housing options for program participants requires strong partnerships between housing and service providers.  Many programs use tenant-based rent subsidies, and cultivate relationships with landlords who are willing to accept tenants who have poor credit or a history of prior evictions.  Some programs offer access to permanent supportive housing where health care and other support services are available on-site. Housing options must be safe and accessible for persons with disabilities or health conditions that may limit mobility.  Prior to placement in permanent housing, hospitals can refer patients to medical respite programs for those who are ready to be discharged from a hospital but too sick or frail to recover on the streets or in shelters.

Patient-centered Health Services

Patient-centered health servicesare most effective when primary care and behavioral health services are integrated or closely coordinated.  Access to primary and specialty care services to address medical needs, which may be quite serious, is essential but may not be sufficient to improve health outcomes or reduce hospitalizations absent a change in clients’ behavior. Motivational interviewing and harm reduction strategies are used to address problems related to substance use and mental illness, as well as chronic health conditions, and to promote healthier behaviors and better management of chronic conditions. 

In designing and implementing supportive services for program participants, providers must ensure that staffing levels are adequate and that staff members have the skills and training needed to safely and effectively serve people with complex health conditions.  In some communities health services linked to housing for frequent users experiencing homelessness are provided by Health Care for the Homeless programs or other Community Health Centers that operate as Federally Qualified Health Centers (FQHC).

Use Data to Demonstrate Outcomes

Using data to measure changes in service utilization, costs, and health outcomes, and to make the case for funding to sustain and replicate effective programs and practices will help Frequent User programs be successful and expand.  Many frequent user programs start small, often relying on time-limited funding from foundations or other one-time grants. As increasing numbers of people are enrolled in Medicaid managed care plans, support may also come through grants or contracts with managed care organizations. When data shows that the programs are producing results that include reductions in hospital emergency room visits, inpatient hospitalizations, or utilization of other high-cost services, policy-makers, hospital administrators, and managed care organizations could be more willing to commit ongoing funding to sustain and expand effective programs.

Implementation Steps/Tips:

Frequent User programs vary in size and focus, the types of organizations and partnerships responsible for leadership and implementation, and the housing and services they offer.  Promising programs share several core components or strategies that often include:

  • Data analysis to identify the most frequent users of costly health services and other highly vulnerable homeless people who are likely to have avoidable emergency room visits and inpatient hospitalizations;
  • Effective outreach and engagement strategies that establish trust and overcome barriers resulting from isolation, stigma, and the symptoms of mental health and/or substance use problems;
  • Strong partnerships that include information sharing, with appropriate privacy safeguards,among care providers who work in the hospital, discharge planners, and health care and service providers who work in community settings and organizations;
  • Integrated care for medical, mental health, and substance use conditions and coordination of care among providers;
  • Cross-system relationships and connections to a range of services to facilitate access and collaborative problem-solving to achieve shared goals for shared clients;
  • Medical respite programs for people are ready to be discharged from a hospital but too sick or frail to recover on the streets or in shelters.
  • Access to affordable and supportive housing using a Housing First approach, including individualized help getting and keeping housing that is accessible and appropriate for persons with disabilities and health-related vulnerabilities;
  • Practical and sustained support to meet basic needs and respond to individual preferences;
  • Trauma-informed services that restore hope; and
  • Motivational Interviewing and harm reduction services to help people change harmful and risky behaviors.


Frequent User programs have produced impressive results that include substantial reductions in emergency room visits, inpatient hospital admissions and days of inpatient hospital stays, and use of other costly emergency and institutional services such as ambulances, detox or sobering centers, jail medical or psychiatric care, and skilled nursing facilities or nursing homes.  Programs that offer services connected to permanent housing achieve greater reductions in avoidable emergency room visits and inpatient hospitalizations, compared to programs that offer services without housing.  Other outcomes include connections to community clinics or other sources of ongoing primary health care and engagement in mental health and substance abuse treatment services, and reductions in mortality, as well as connections to permanent housing and other services to support housing stability and recovery.

Contact Info for Follow-up: 

The Corporation for Supportive Housing convened a National Frequent Users Forum in 2008.  A report summarizing the themes and findings from the forum, with descriptions and outcome information from several promising programs, is available on the CSH website at

The Lewin Group completed an evaluation of California’s Frequent Users of Health Services Initiative, which provided planning and implementation grants to support projects in 8 counties in California.  A summary report describing highlights of the Initiative’s evaluation results is available here.

Funded by the Conrad N. Hilton Foundation, the Economic Roundtable and the Corporation for Supportive Housing are implementing the FUSE Frequent Users Housing Initiative: a pilot project to use a new screening / triage tool for identifying high-cost, high-need homeless persons among hospital inpatients, emergency room patients, and jail inmates. The tool, developed by the Economic Roundtable, will be used to prioritize high-cost, high-need homeless persons for placement into permanent supportive housing. The tool is based on findings from two of the Economic Roundtable's recent policy research studies, Where We Sleep: The Costs of Housing and Homelessness in Los Angeles (2009) and Tools for Identifying High-Cost, High-Need Homeless Persons (2010).  For more information about the Initiative and links to the reports see

The Corporation for Supportive Housing has also prepared short profiles of projects that identify, serve, and house the most frequent users of emergency room care and other costly health services, including San Francisco’s Direct Access to Housing

and Berkeley’s Lifelong Medical Care

Related Profiles:

Evidence-Based Practice:  Permanent Supportive Housing

Evidence-Based Practice:  Housing First

Evidence-Based Practice:  Medical Respite

Evidence-Based Practice:  Motivational Interviewing

Promising Practice:  Frequent Users Systems Engagement (FUSE)

Model Program:  New Directions (Santa Clara County CA)

Model Program:  Chicago Housing for Health Partnership (Chicago, IL)

Model Program: 1811 Eastlake (Seattle WA)