Adults experiencing homelessness or housing instabilityhave disproportionately high rates of interaction with correctional and emergency health care systems. Although these encounters are often managed asisolated events, they frequently represent a recurring cycle driven by broadermedical and social needs. Reduced access to longitudinal health care and socialbenefits/connectedness contribute to disproportionately high utilization ofemergency health care services and repeated incarceration. Reducing recurrentincarceration will require earlier identification of vulnerable individuals andgreater 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 becomeincarcerated because of the vulnerabilities associated with homelessness orhousing instability. They disproportionately rely on crisis systems due tolimited access to resources such as mental health services, substance usetreatment, and medical care. This often creates a repetitive cycle of emergencysystem use rather than addressing the root causes. By recognizing the earlysigns of entering this cycle, individuals experiencing homelessness or housinginstability could be identified earlier, leading to more effective holisticinterventions.
Why Earlier Intervention Matters
Housing instability alone does not fully explain the highutilization of crisis and correctional systems. Social and health factorsassociated with housing instability contribute substantially to these interactions.Housing instability often brings other hardships, including limited access tohealth care and other services. These vulnerabilities are linked to frequentinteractions with emergency health care and correctional systems. Crisissystems are focused on responding to the immediate problem and may not addressthe broader medical and social factors that contribute to recurrentincarceration. These patterns occur across systems: patients experiencinghomelessness have higher rates of hospital readmissions and emergencydepartment (ED) revisits, while housing instability following incarceration isassociated with recurrent correctional system involvement, as these individualsare unable to develop a foundational base from which to live and work in orderto maintain independence. Reincarceration and housing loss may reinforce oneanother, contributing to a cycle of instability. Earlier intervention couldcreate an opportunity to address unmet medical and social needs beforeindividuals struggling with housing instability fall into a cycle of repeatedcrisis system utilization and involvement with the correctional system.
Emergency health care utilization, housing instability, andcorrectional-system involvement often overlap among vulnerable populations. Ithas been found that nearly a quarter of incarcerated individuals experiencedhomelessness around the time of imprisonment, with the prevalence approachingone-third at the time of release. The same underlying vulnerability can lead tointeractions with different crisis systems depending on the circumstances of anindividual encounter. For example, behavioral health crises may lead to an EDencounter or correctional system involvement. Looking at just one system mayprovide an incomplete picture of an individual’s broader pattern of crisissystem interactions. Certain medical and behavioral health vulnerabilities areassociated with recurrent emergency health care utilization after release fromprison. Individuals with diagnoses of mental illness alone or combined withsubstance use have a higher risk of frequent ED utilization. Housing loss iscommon following release from jail or prison, even among individuals previously housed in stable environments.Housing loss following jail incarceration is also associated with an increasedlikelihood of reincarceration. These associations suggest that housinginstability and involvement in the correctional system may reinforce oneanother, contributing to a recurring cycle of instability.
Repeated Emergency Health Care 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 ofother emergency-response systems. Depending on the nature of the call, EMS andlaw enforcement may respond to the same incident, with either system playing agreater role based on the circumstances. This overlap creates another pointwhere an individual's medical, behavioral, and social needs may intersect withboth emergency health care and the correctional system.
Evidence shows EMS can do more than recognize patterns offrequent utilization. A study in San Francisco identified frequent EMS usersand contacted them through an EMS-based outreach team that considered medicaland psychosocial needs and connected individuals with services includingprimary care, case management, and/or substance-use treatment. Following thisintervention, EMS utilization decreased by about half. Although an EMS-ledimplementation of interventions may be unrealistic in many circumstances, thisstudy highlights the potential benefits of using EMS encounters as anopportunity to identify individuals in need and connect them to appropriateservices.
Similar approaches have been used in the ED setting. Peopleexperiencing homelessness, mental health issues, or social challenges have beenidentified as frequent utilizers of emergency departments. A scoping review ofinterventions for these populations identified case management and housingsupport as key methods for addressing recurrent utilization. Theseinterventions aim to address needs beyond an emergency encounter and reduce theunderlying factors that contribute to it. The findings suggest that emergencyhealth care encounters may be an opportunity to identify individuals withcomplex needs and connect them with the most appropriate and effectiveresources.
The overlap in housing instability, mental illness, andsubstance use, along with the frequent overlap of EMS and law enforcement wheninteracting with certain individuals, suggests that repeated emergency healthencounters may be able to provide an earlier view of the same broader cycle ofvulnerability. Effective intervention requires addressing the underlyingmedical and social vulnerabilities that contribute to interactions with crisissystems, rather than assessing each interaction individually. These vulnerabilitiescan include mental illness, substance use disorders, physical or developmentalimpairments, unemployment, housing instability, limited education, poor socialand support networks, among others. Identification can then guideindividualized multidisciplinary responses, including longitudinal medicalcare, mental health care, substance use treatment, housing and social services,and case management. Because needs often span multiple factors, a single systemmay not be enough. Case management can coordinate services for individuals withcomplex needs, often through interdisciplinary care. In this approach, EMSwould focus on recognition and referral, while appropriate health care andsocial service providers would carry out the interventions.
Frequent EMS users and individuals with recurrentcorrectional system involvement share many of the medical and socialvulnerabilities discussed so far. Recognizing these shared vulnerabilities maycreate opportunities to identify needs that stretch beyond the brief encounter.Recognition means identifying underlying factors and unmet needs that maycontribute to recurrent encounters. EMS would identify these patterns and referindividuals to the appropriate services. However, for this to be effective, anadequate system must be in place to receive such EMS referrals. These referralsshould lead to individualized approaches tailored to each person's needs, asneeds can differ between individuals.
Interventions That Can Reduce Correctional-SystemInvolvement:
Earlier identification would be most valuable when itconnects individuals with existing interventions that address vulnerabilitiescontributing to correctional system involvement. Effective interventionsalready exist, allowing greater emphasis to be placed on early identificationand connection to established programs.
One example of an effective housing intervention isWashington's Reentry Housing Pilot Program (RHPP), which targeted high-risk,high-need individuals leaving prison who , lacked suitable housing upon reentry. The program combined housingassistance with wraparound services, an individualized approach thatcoordinated multiple support systems and care around the individual and theirfamily's needs. This approach addresses multiple unmet needs together ratherthan treating each need in isolation. The study found that participants in theprogram had significantly fewer new convictions and prison readmissions thanthe comparison group.
However, housing interventions may not have the same effectacross all populations. A systematic review of Housing First among peopleexperiencing homelessness and serious mental illness found little overalleffect on correctional system involvement. Substance-use treatment may provideanother intervention. Substance use can affect physical and mental health andcreate barriers to employment, housing stability, and meeting basic needs.Substance use treatment can provide structure and address health needs whileconnecting individuals with support and other potentially helpful resources.Among recently released men experiencing homelessness, participation instructured substance use programs and longer engagement in residential drugtreatment 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 andphysical health and increase vulnerability to homelessness and substance use.Employment can provide structure and income while increasing stability. Amongveterans experiencing homelessness and substance use, participation in acompensated work therapy program was associated with fewer episodes of homelessnessand 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 health care. 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 alsoappear among individuals with recurrent correctional system involvement. Ratherthan viewing recurrent interactions within each system independently,recognizing patterns across systems could create opportunities for earlieridentification and connection to appropriate interventions. Recognizing abroader pattern before repeated encounters become a recurring cycle may allowearlier attention to unmet medical and social needs, rather than responding toeach interaction in isolation. This approach could benefit vulnerableindividuals while reducing recurrent emergency health care use and involvementin the correctional system. Creating clear pathways from encounters to patternrecognition and connecting individuals with effective, individualizedinterventions may turn repeated EMS use and recurrent involvement with thecorrectional system into opportunities for earlier, more comprehensiveintervention.
References:
Ager, Emily E., et al. “Homelessness Following Jail ExitAmong Previously Housed Individuals.” Journal of Urban Health, vol. 102,no. 5, Oct. 2025, pp. 977–88, https://doi.org/10.1007/s11524-025-01016-4.
Bashir, Ahmad Y., et al. “From Nowhere to Nowhere.Homelessness and Incarceration: A Systematic Review and Meta-Analysis.” International Journal of Prisoner Health, https://doi.org/10.1108/ijph-01-2021-0010.
Butler, Amanda, et al. “Frequent Attendance to the Emrgency Department After Release From Prison: A Prospective Data Linkage Study.” The Journal of Behavioral Health Services & Research, vol. 47, no. 4, Dec.2019, pp. 544–59, https://doi.org/10.1007/s11414-019-09685-1.
Chen, Nadine E., et al. “Adherence to HIV Treatment and CareAmong Previously Homeless Jail Detainees.” AIDS and Behavior [UnitedStates], vol. 17, no. 8, Oct. 2013, PubMed Central, pp. 2654–66, https://doi.org/10.1007/s10461-011-0080-2.
Davis, Rebekah A., et al. “Strategies to Reduce FrequentEmergency Department Use Among Persons Experiencing Homelessness With MentalHealth Conditions: A Scoping Review.” Journal of Urban Health, vol. 101,no. 5, Sept. 2024, pp. 968–78, https://doi.org/10.1007/s11524-024-00917-0.
Kashner, Michael T., et al. “Impact of Work Therapy onHealth Status Among Homeless, Substance-Dependent Veterans: A RandomizedControlled Trial.” Arch Gen Psychiatry, vol. 59, no. 10, Oct. 2002, pp.938–44, https://doi.org/10.1001/archpsyc.59.10.938.
Leclair, Marichelle C., et al. “The Impact of Housing Firston Criminal Justice Outcomes Among Homeless People With Mental Illness: ASystematic Review.” The Canadian Journal of Psychiatry, vol. 64, no. 8,Jan. 2019, p. 070674371881590, https://doi.org/10.1177/0706743718815902.
Lutze, Faith E., et al. “Homelessness and Reentry: AMultisite Outcome Evaluation of Washington State’s Reentry Housing Program forHigh Risk Offenders.” Criminal Justice and Behavior, vol. 41, no. 4,Dec. 2013, pp. 471–91, https://doi.org/10.1177/0093854813510164.
Miyawaki, Atsushi, et al. “Hospital Readmission andEmergency Department Revisits of Homeless Patients Treated at Homeless-ServingHospitals in the USA: Observational Study.” Journal of General InternalMedicine, vol. 35, no. 9, July 2020, pp. 2560–68, https://doi.org/10.1007/s11606-020-06029-0.
Nyamathi, Adeline, Benissa E Salem, et al. “Impact of anIntervention for Recently Released Homeless Offenders on Self-ReportedRe-Arrest at 6 and 12 Months.” Journal of Addictive Diseases [England],vol. 36, no. 1, 2017, PubMed, pp. 60–71, https://doi.org/10.1080/10550887.2016.1147796.
Nyamathi, Adeline, Sanghyuk S. Shin, et al. “Effectivenessof Dialectical Behavioral Therapy on Reduction of Recidivism Among RecentlyIncarcerated Homeless Women: A Pilot Study.” International Journal ofOffender Therapy and Comparative Criminology, vol. 62, no. 15, July 2018,pp. 4796–813, https://doi.org/10.1177/0306624x18785516.
Tangherlini, Niels, et al. “The HOME Team: Evaluating theEffect of an EMS-Based Outreach Team to Decrease the Frequency of 911 Use AmongHigh Utilizers of EMS.” Prehospital and Disaster Medicine, vol. 31, no.6, Sept. 2016, pp. 603–07, https://doi.org/10.1017/s1049023x16000790.
Washington, Melvin. “Beyond Jails: Community-BasedStrategies for Public Safety.” Vera Institute of Justice, Nov. 2021, https://www.vera.org/beyond-jails-community-based-strategies-for-public-safety.
