Homelessness Drives Up No-Show Rates for Virtual Addiction Treatment

Using telehealth for substance use disorder treatment may only see success for people with stable housing, as no-show rates for virtual visits were higher for people experiencing homelessness, a study published in the Asian Journal of Psychiatry revealed.

At the onset of the COVID-19 pandemic, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed certain restrictions for substance use disorder treatment. The administration expanded telehealth use and allowed providers to evaluate and treat patients virtually to avoid exposure to the coronavirus.

Expanding virtual care services can help increase access to care and eliminate barriers such as finding transportation and taking time off work, but telehealth may also exacerbate care disparities for people experiencing homelessness who may not have reliable access to technology or the internet.

Researchers retrospectively analyzed substance use disorder visits at Denver Health Behavioral Health Center between March 1 and Sept. 30, 2020, to understand how housing status influenced appointment no-show rates. The health center implemented a telehealth program in March 2020.

There were 18,206 visits for substance use disorder treatment among 1,626 patients over the study period. Nearly a quarter of the patients (387) were experiencing homelessness and accounted for 4,237 of the visits, according to the researchers. Patients experiencing homelessness were more likely to be male, to be between the ages of 35 and 49, and identify as white, compared to patients who were stably housed.

People experiencing homelessness were less likely to have a telehealth visit than people with stable housing — 35.5 percent versus 54.8 percent.

Additionally, people experiencing homelessness had slightly higher no-show rates (33.1 percent) for both in-person and virtual care as compared with their stably housed counterparts (27.2 percent). 

However, when looking at only virtual visits, this difference was more significant. Only a quarter of stably housed patients missed a telehealth visit, compared to 37 percent of patients experiencing homelessness. In contrast, when comparing missed visit rates for in-person appointments, there was no significant difference between patients experiencing homelessness and stably housed patients.

The study results indicate that while telehealth may present a more convenient care option for patients who have stable housing, it may create an additional barrier for patients experiencing homelessness.

People experiencing homelessness were more likely to miss a virtual visit compared to stably housed patients, which could be attributed to a lack of access to the proper resources needed for virtual care.

“Access to key infrastructure components, including telephones, internet, and private or safe space, is vital for use of behavioral healthcare through telehealth,” the researchers wrote. “It is plausible that [people experiencing homelessness] lack stable access to these components essential to complete appointments.”

The researchers referenced data from a past program at Denver Health that provided cell phones to people experiencing homelessness in an attempt to improve access to virtual care. However, simply offering the proper technology did not reduce barriers, suggesting that health systems and other healthcare stakeholders must approach the issue more holistically.

The results also revealed that once these barriers are addressed, telehealth has the potential to increase access to substance use disorder treatment, as stably housed patients had higher no-show rates for in-person visits compared to telehealth visits.

“For individuals who have the resources, access to and an option to use telehealth has provided them with an opportunity to better manage their healthcare utilization during this pandemic,” the study stated.

In general, telehealth has increased access to mental and behavioral healthcare services during the pandemic.

Study authors added that further research is needed to implement programs that will allow people experiencing homelessness to access this critical care more feasibly via telehealth.