Adults experiencing homelessness or housing instability have disproportionately high rates of interaction with correctional and emergency healthcare systems. Although these encounters are often managed as isolated events, they frequently represent a recurring cycle driven by broader medical and social needs. Reduced access to longitudinal healthcare and social benefits/connectedness contribute to disproportionately high utilization of emergency healthcare services and repeated incarceration. Reducing recurrent incarceration will require earlier identification of vulnerable individuals and greater use of effective interventions such as engaged case management, housing, and access to multi-pronged treatment strategies.
Introduction
Many individuals in the criminal justice system become incarcerated because of the vulnerabilities associated with homelessness or housing instability. They disproportionately rely on crisis systems due to limited access to resources such as mental health services, substance use treatment, and medical care. This often creates a repetitive cycle of emergency system use rather than addressing the root causes. By recognizing the early signs of entering this cycle, individuals experiencing homelessness or housing instability could be identified earlier, leading to more effective holistic interventions.
Why Earlier Intervention Matters
Housing instability alone does not fully explain the high utilization of crisis and correctional systems. Social and health factors associated with housing instability contribute substantially to these interactions. Housing instability often brings other hardships, including limited access to healthcare and other services. These vulnerabilities are linked to frequent interactions with emergency healthcare and correctional systems. Crisis systems are focused on responding to the immediate problem and may not address the broader medical and social factors that contribute to recurrent incarceration. These patterns occur across systems: patients experiencing homelessness have higher rates of hospital readmissions and emergency department (ED) revisits, while housing instability following incarceration is associated with recurrent correctional system involvement, as these individuals are unable to develop a foundational base from which to live and work in order to maintain independence. Reincarceration and housing loss may reinforce one another, contributing to a cycle of instability. Earlier intervention could create an opportunity to address unmet medical and social needs before individuals struggling with housing instability fall into a cycle of repeatedcrisis system utilization and involvement with the correctional system.
Emergency healthcare utilization, housing instability, and correctional-system involvement often overlap among vulnerable populations. It has been found that nearly a quarter of incarcerated individuals experienced homelessness around the time of imprisonment, with the prevalence approaching one-third at the time of release. The same underlying vulnerability can lead to interactions with different crisis systems depending on the circumstances of an individual encounter. For example, behavioral health crises may lead to an ED encounter or correctional system involvement. Looking at just one system may provide an incomplete picture of an individual’s broader pattern of crisis system interactions.
Certain medical and behavioral health vulnerabilities are associated with recurrent emergency healthcare utilization after release from prison. Individuals with diagnoses of mental illness alone or combined with substance use have a higher risk of frequent ED utilization. Housing loss is common following release from jail or prison, even among individuals previously housed in stable environments.Housing loss following jail incarceration is also associated with an increased likelihood of reincarceration. These associations suggest that housing instability and involvement in the correctional system may reinforce one another, contributing to a recurring cycle of instability.
Repeated Emergency Healthcare Encounters as an Opportunity for Earlier Intervention
Frequent users account for a substantial amount of EMS (Emergency Medical Services) utilization, with housing status, mental illness, and substance use as major contributing factors. A pattern of repeated EMS interactions may suggest broader unmet medical and social needs. EMS provides a unique perspective because they encounter individuals as first responders in unstable housing situations in their communities (e.g., on the streets, shelters) rather than as second responders in the jail/prison setting. As such, frequent EMS utilization has been used to initiate outreach to frequent EMS users.
EMS encounters also do not always occur independently of other emergency-response systems. Depending on the nature of the call, EMS and law enforcement may respond to the same incident, with either system playing a greater role based on the circumstances. This overlap creates another point where an individual's medical, behavioral, and social needs may intersect with both emergency healthcare and the correctional system.
Evidence shows EMS can do more than recognize patterns of frequent utilization. A study in San Francisco identified frequent EMS users and contacted them through an EMS-based outreach team that considered medicaland psychosocial needs and connected individuals with services including primary care, case management, and/or substance-use treatment. Following this intervention, EMS utilization decreased by about half. Although an EMS-led implementation of interventions may be unrealistic in many circumstances, this study highlights the potential benefits of using EMS encounters as an opportunity to identify individuals in need and connect them to appropriate services.
Similar approaches have been used in the ED setting. People experiencing homelessness, mental health issues, or social challenges have been identified as frequent utilizers of emergency departments. A scoping review of interventions for these populations identified case management and housing support as key methods for addressing recurrent utilization. These interventions aim to address needs beyond an emergency encounter and reduce the underlying factors that contribute to it. The findings suggest that emergency healthcare encounters may be an opportunity to identify individuals with complex needs and connect them with the most appropriate and effective resources.
The overlap in housing instability, mental illness, and substance use, along with the frequent overlap of EMS and law enforcement when interacting with certain individuals, suggests that repeated emergency healthcare encounters may be able to provide an earlier view of the same broader cycle of vulnerability.
Effective intervention requires addressing the underlying medical and social vulnerabilities that contribute to interactions with crisis systems, rather than assessing each interaction individually. These vulnerabilities can include mental illness, substance use disorders, physical or developmental impairments, unemployment, housing instability, limited education, poor social and support networks, among others. Identification can then guide individualized multidisciplinary responses, including longitudinal medical care, mental healthcare, substance use treatment, housing and social services,and case management. Because needs often span multiple factors, a single system may not be enough. Case management can coordinate services for individuals with complex needs, often through interdisciplinary care. In this approach, EMS would focus on recognition and referral, while appropriate healthcare and social service providers would carry out the interventions.
Frequent EMS users and individuals with recurrent correctional system involvement share many of the medical and social vulnerabilities discussed so far. Recognizing these shared vulnerabilities may create opportunities to identify needs that stretch beyond the brief encounter. Recognition means identifying underlying factors and unmet needs that may contribute to recurrent encounters. EMS would identify these patterns and refer individuals to the appropriate services. However, for this to be effective, an adequate system must be in place to receive such EMS referrals. These referrals should lead to individualized approaches tailored to each person's needs, as needs can differ between individuals.
Interventions That Can Reduce Correctional-System Involvement
Earlier identification would be most valuable when it connects individuals with existing interventions that address vulnerabilities contributing to correctional system involvement. Effective interventions already exist, allowing greater emphasis to be placed on early identification and connection to established programs.
One example of an effective housing intervention is Washington's Reentry Housing Pilot Program (RHPP), which targeted high-risk, high-need individuals leaving prison who lacked suitable housing upon reentry. The program combined housing assistance with wraparound services, an individualized approach that coordinated multiple support systems and care around the individual and theirfamily's needs. This approach addresses multiple unmet needs together rather than treating each need in isolation. The study found that participants in the program had significantly fewer new convictions and prison readmissions than the comparison group.
However, housing interventions may not have the same effect across all populations. A systematic review of Housing First among people experiencing homelessness and serious mental illness found little overall effect on correctional system involvement.
Substance-use treatment may provide another intervention. Substance use can affect physical and mental health and create barriers to employment, housing stability, and meeting basic needs. Substance use treatment can provide structure and address health needs while connecting individuals with support and other potentially helpful resources. Among recently released men experiencing homelessness, participation in structured substance use programs and longer engagement in residential drug treatment were associated with a lower likelihood of rearrest.
Behavioral interventions can also address vulnerabilities that contribute to repeated involvement in the correctional system. Among recently incarcerated women experiencing homelessness, dialectical behavior therapy combined with case management provided coping and behavioral skills while connecting individuals with resources to meet their socioeconomic needs. This intervention was associated with a lower recidivism rate, particularly among participants who expressed a greater desire for help, suggesting that individuals may require different approaches and respond differently to certain interventions.
Another example includes employment-based interventions, which can address multiple factors simultaneously. Unemployment can contribute to social and financial instability, which may adversely affect mental and physical health and increase vulnerability to homelessness and substance use. Employment can provide structure and income while increasing stability. Among veterans experiencing homelessness and substance use, participation in a compensated work therapy program was associated with fewer episodes of homelessness and incarceration compared with veterans who did not participate.
These examples represent only some interventions that may suit each individual's needs, alongside mental health services and longitudinal healthcare. Together, these interventions suggest shifting focus to the social and medical factors contributing to reincarceration. For more individualized coordination, case management can connect individuals with the specific resources most relevant and useful to them. The goal of earlier recognition should be to create clear pathways from crisis-system encounters to the existing housing, healthcare, behavioral health, and social resources that are appropriate and most relevant for each individual.
Conclusion
Many vulnerabilities among frequent crisis system users also appear among individuals with recurrent correctional system involvement. Rather than viewing recurrent interactions within each system independently, recognizing patterns across systems could create opportunities for earlieridentification and connection to appropriate interventions. Recognizing a broader pattern before repeated encounters become a recurring cycle may allow earlier attention to unmet medical and social needs, rather than responding to each interaction in isolation. This approach could benefit vulnerable individuals while reducing recurrent emergency healthcare use and involvement in the correctional system. Creating clear pathways from encounters to pattern recognition and connecting individuals with effective, individualized interventions may turn repeated EMS use and recurrent involvement with thecorrectional system into opportunities for earlier, more comprehensive intervention.
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