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Feldman BJ, Kim JS, Mosqueda L, Vongsachang H, Banerjee J, Coffey CE, Spellberg B, Hochman M, Robinson J. From the hospital to the streets: Bringing care to the unsheltered homeless in Los Angeles. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100557. [PMID: 34052622 DOI: 10.1016/j.hjdsi.2021.100557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 11/18/2022]
Abstract
Homelessness is a neglected crisis throughout the United States. In Los Angeles (L.A.) County, nearly 59,000 residents are homeless, and the vast majority are unsheltered. An academic institution and L.A county's largest public hospital formed a partnership to launch a Street Medicine (SM) program. SM assists the inpatient team with discharge planning and builds rapport with the patient experiencing homelessness. After discharge, the SM team follows up and brings care to the patient on the streets, often developing a trusting relationship and establishing continuity of primary care. During a 12-month period, SM provided inpatient consults for 206 unsheltered homeless patients.
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Affiliation(s)
- Brett J Feldman
- Department of Family Medicine, Keck School of Medicine, USC, Los Angeles, CA, USA.
| | - Jeniffer S Kim
- Gehr Family Center for Health Systems Science and Innovation, USC, Los Angeles, CA, USA.
| | - Laura Mosqueda
- Department of Family Medicine, Keck School of Medicine, USC, Los Angeles, CA, USA.
| | - Hurnan Vongsachang
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
| | - Josh Banerjee
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
| | - Charles E Coffey
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
| | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
| | - Michael Hochman
- Gehr Family Center for Health Systems Science and Innovation, USC, Los Angeles, CA, USA; Department of Clinical Medicine, Keck School of Medicine, USC, Los Angeles, CA, USA.
| | - Jehni Robinson
- Department of Family Medicine, Keck School of Medicine, USC, Los Angeles, CA, USA.
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Lin LP, Wang LY, Wang TW, Chen YC, Lin JD. Factors Associated with Free Hospital Outpatient Service Use among Middle-Aged and Older Urban Homeless Adults in Taipei. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105330. [PMID: 34067784 PMCID: PMC8156856 DOI: 10.3390/ijerph18105330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022]
Abstract
Homeless individuals have many negative experiences with inequality regarding access to and the use of primary healthcare services, so policies to eliminate the disparities in and barriers to primary care access for these people are needed. The aim of this study was to explore the use and determinants of free hospital outpatient services for homeless people, in order to describe the provision of free healthcare policies for this vulnerable population in Taipei. One cross-sectional survey was conducted to recruit homeless people aged 45 years old and over in Taipei in 2018. A structured questionnaire was used, and face-to-face interviews were conducted by three social workers to collect the data. Finally, 129 participants were recruited in the study. The results show that 81.4% of the homeless people had made free hospital outpatient care visits (mean = 5.9 visits) in the last three months. An unadjusted logistic regression analysis showed that those homeless people who reported having usual healthcare providers, with higher depressive symptom scores, who used medication and had been hospitalized within one year, and had more chronic diseases, were significantly more likely to make free hospital outpatient visits. The adjusted logistic regression model indicates that homeless people with severe depressive symptoms (odds ratio (OR) = 9.32, 95% CI = 1.15–56.07), who had received medication (OR = 3.93; 95% CI = 1.06–14.52), and who had more than five chronic diseases (OR = 1.06, 95% CI = 1.35–13.27), were significantly more likely to make free hospital outpatient visits than their counterparts. The findings highlight that homeless people have higher healthcare requirements than the general population, and the healthcare system should pay more attention to factors associated with higher outpatient service use, such as homelessness, severe depressive symptoms, the receipt of medication and chronic diseases.
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Affiliation(s)
- Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Li-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Jin-Ding Lin
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence:
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53
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Koh KA, Racine M, Gaeta JM, Goldie J, Martin DP, Bock B, Takach M, O'Connell JJ, Song Z. Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations. Health Aff (Millwood) 2021; 39:214-223. [PMID: 32011951 DOI: 10.1377/hlthaff.2019.00687] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.
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Affiliation(s)
- Katherine A Koh
- Katherine A. Koh ( kkoh@partners. org ) is a physician at the Boston Health Care for the Homeless Program and Massachusetts General Hospital, both in Boston, Massachusetts
| | - Melanie Racine
- Melanie Racine is the director of special projects at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care
| | - Jessie M Gaeta
- Jessie M. Gaeta is chief medical officer at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care. She is also an assistant professor of medicine at Boston University School of Medicine
| | - John Goldie
- John Goldie is executive director of system analytics, Boston Medical Center Health System
| | - Daniel P Martin
- Daniel P. Martin is a data scientist in the Population Health Analytics and Strategy team, Boston Medical Center Health System
| | - Barry Bock
- Barry Bock is chief executive officer of the Boston Health Care for the Homeless Program
| | - Mary Takach
- Mary Takach is a senior health policy adviser at the Boston Health Care for the Homeless Program
| | - James J O'Connell
- James J. O'Connell is president of the Boston Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School, in Boston
| | - Zirui Song
- Zirui Song is an assistant professor of health care policy and medicine at Harvard Medical School and Massachusetts General Hospital, and a faculty member in the Center for Primary Care at Harvard Medical School
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Kneck Å, Mattsson E, Salzmann-Erikson M, Klarare A. "Stripped of dignity" - Women in homelessness and their perspectives of healthcare services: A qualitative study. Int J Nurs Stud 2021; 120:103974. [PMID: 34087526 DOI: 10.1016/j.ijnurstu.2021.103974] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A much more substantial European evidence base on the accessibility of healthcare services among women experiencing homelessness across healthcare systems in Europe is warranted. OBJECTIVE To give voice to women with experiences of homelessness, and to explore their perspectives of healthcare services in an EU country with universal healthcare. DESIGN The study is part of a research program striving to promote equal healthcare through co-production with women in homelessness. An advisory board of women with lived experience of homelessness was established and a qualitative, interpretive and exploratory design was employed. PARTICIPANTS 26 women with experience of homelessness were interviewed. Their median age was 46 years (range 42) and 70% were roofless/houseless. METHODS Data were analyzed with content analysis. Co-production and joint analyses were conducted by researchers and three women with experience of homelessness, using the DEPICT model for collaborative analysis. RESULTS The analysis resulted in one overall theme: Visiting healthcare from the outskirts of society, comprising three sub-themes: Demand for a life in order - Exclusion in action; Unwell, unsafe and a woman - Multifaceted needs challenge healthcare; and Abuse versus humanity - power of healthcare encounters to raise or reduce. Women's experiences of care encounters were disparate, with prevalent control, mistrust and stigma, yet healthcare professionals that demonstrated respect for the woman's human dignity was described both as life-altering and lifesaving. CONCLUSIONS Women in homelessness live on the outskirts of society and have multiple experiences of exclusion and loss of dignity within healthcare services. The multifaceted care needs challenge healthcare, leading to women feeling alienated, invisible, disconnected and worthless. We urge registered nurses to take actions for inclusion health, i.e. focusing health efforts of people experiencing extreme health inequities. We can lead the way by speaking up and confronting discriminating behaviors, protecting and restoring human dignity in caring relationships, and framing healthcare services for all citizens. Tweetable abstract: Women in homelessness have multiple experiences of exclusion and loss of dignity within healthcare services. Nurses must frame healthcare to include all citizens.
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Affiliation(s)
- Åsa Kneck
- Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Stigbergsgatan 30, Box 111 89, 100 61, Stockholm, Sweden.
| | - Elisabet Mattsson
- Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Stigbergsgatan 30, Box 111 89, 100 61, Stockholm, Sweden; Uppsala University, Department of Women's and Children's Health, Clinical psychology in healthcare, 751 85, Uppsala, Sweden.
| | - Martin Salzmann-Erikson
- University of Gävle, Faculty of Health and Occupational Studies, Department of Caring Sciences, 801 76, Gävle, Sweden.
| | - Anna Klarare
- Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Stigbergsgatan 30, Box 111 89, 100 61, Stockholm, Sweden; Uppsala University, Department of Women's and Children's Health, Clinical psychology in healthcare, 751 85, Uppsala, Sweden.
| | -
- Ersta Möjlighet, Stockholm, Sweden
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Gil-Salmeron A, Smith L, Yang L, Rieder A, Grabovac I. Differences in health status, health behaviour and healthcare utilisation between Immigrant and native homeless people in Spain: An exploratory study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:856-866. [PMID: 33586224 DOI: 10.1111/hsc.13313] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/09/2020] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Abstract
Few studies have examined the differences between immigrant and native-born homeless populations. Our aim was to conduct an exploratory study to examine the differences in health status, health behaviour and healthcare utilisation in a sample of Spanish immigrant and native homeless people. Study was conducted in eight different temporary accommodations in the Valencia region in August 2018. Overall, 86 participants were included in the analysis who answered questionnaires concerning socio-demographic characteristics, immigration status, health status and behaviour, healthcare utilisation and experienced discrimination in healthcare and health literacy. In total, 76.7% were men with a mean age of 41.91 (14.17) years, with 60.4% having immigration background with an average of 4.8 (4.2) years since arrival in Spain. No differences were found in the subjective health status, however, native homeless participants reported significantly higher prevalence of heart disease (87.5% vs. 12.5%), hypertension (84.6% vs. 15.4%), psychological illness (63.6% vs. 36.4%) and were also more often smokers (73.5% vs. 28.8%), reported smoking more cigarettes per day (12.0 vs. 7.4) and were more often illegal drug users (17.6% vs. 2.0%). Immigrant participants were significantly more often not insured, reported more problems in healthcare access and had lower rates of visits to general practitioners and less hospital admissions. Differences were also observed in social status with the native homeless more often reporting receiving income, and living in less crowded accommodations. Our results show a variety of issues that the immigrant homeless population in Spain is confronted with that also prevents adequate social inclusion and achieving good health. However, the immigrant population engaged less often in risky health behaviour. More, and continuous, monitoring of social, mental and physical health of the homeless population is necessary. Public health interventions aiming at health promotion in the immigrant homeless populations need to focus on increasing overall social integration.
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Affiliation(s)
- Alejandro Gil-Salmeron
- Polibenestar Research Institute, University of Valencia, Valencia, Spain
- International Foundation for Integrated Care, Oxford, UK
| | - Lee Smith
- The Cambridge Center for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Canada
- Departments of Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Anita Rieder
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
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56
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Kaltsidis G, Grenier G, Cao Z, L'Espérance N, Fleury MJ. Typology of changes in quality of life over 12 months among currently or formerly homeless individuals using different housing services in Quebec, Canada. Health Qual Life Outcomes 2021; 19:128. [PMID: 33882927 PMCID: PMC8061013 DOI: 10.1186/s12955-021-01768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background In health and social service evaluations, including research on homelessness, quality of Life (QOL) is often used as a key indicator of well-being among service users. However, no typology has been developed on changes in QOL over a 12-month period for a heterogenous sample of homeless individuals. Methods Cluster analysis was employed to identify a typology of change in QOL for 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) and permanent housing (PH) services in Quebec (Canada). Participant interviews were conducted at baseline and 12 months later. An adapted Gelberg–Andersen Model helped organize QOL-related sociodemographic, clinical, and service use variables into predisposing, needs, and enabling factors, respectively. Comparison analyses were performed to determine group differences. Results Four groups emerged from the analyses: (1) young women in stable-PH or improved housing status with moderately high needs and specialized ambulatory care service use, with improved QOL over 12 months; (2) middle-age to older men with stable housing status, few needs and low acute care service use, with most improvement in QOL over 12 months; (3) older individuals residing in stable-PH or improved housing status with very high needs and reduced QOL over 12 months; and (4) men in stable-TH or worse housing status, with high substance use disorder, using few specialized ambulatory care services and showing decline in QOL over 12 months. Conclusions Findings suggest that positive change in QOL over 12 months was mainly associated with fewer needs, and stability in housing status more than housing improvement. Specific recommendations, such as assertive community treatment and harm reduction programs, should be prioritized for individuals with high needs or poor housing status, and among those experiencing difficulties related to QOL, whereas individuals with more favourable profiles could be encouraged to maintain stable housing and use services proportional to their needs.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux, Trois-Rivières, Quebec, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
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57
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Hajek A, Bertram F, Heinrich F, van Rüth V, Ondruschka B, Kretzler B, Schüler C, Püschel K, König HH. Determinants of health care use among homeless individuals: evidence from the Hamburg survey of homeless individuals. BMC Health Serv Res 2021; 21:317. [PMID: 33827570 PMCID: PMC8026095 DOI: 10.1186/s12913-021-06314-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/22/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND To identify the determinants of health care use among homeless individuals. METHODS Data were taken from the Hamburg survey of homeless individuals (n = 100 individuals in the here used model, mean age 44.8 years, SD 12.5) focusing on homeless individuals in Hamburg, Germany. The number of physician visits in the past 3 months and hospitalization in the preceding 12 months were used as outcome measures. Drawing on the Andersen model of health care use as a conceptual framework, predisposing characteristics, enabling resources and need factors as well as psychosocial variables were included as correlates. RESULTS Negative binomial regressions showed that increased physician visits were associated with being female (IRR: 4.02 [95% CI: 1.60-10.11]), absence of chronic alcohol consume (IRR: 0.26 [95% CI: 0.12-0.57]) and lower health-related quality of life (IRR: 0.97 [95% CI: 0.96-0.98]). Furthermore, logistic regressions showed that the likelihood of hospitalization was positively associated with lower age (OR: 0.93 [95% CI: 0.89-0.98]), having health insurance (OR: 8.11 [2.11-30.80]) and lower health-related quality of life (OR: 0.97 [95% CI: 0.94-0.99]). CONCLUSIONS Our study showed that predisposing characteristics (both age and sex), enabling resources (i.e., health insurance) and need factors in terms of health-related quality of life are main drivers of health care use among homeless individuals. This knowledge may assist in managing health care use.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Franziska Bertram
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Heinrich
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Victoria van Rüth
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Kretzler
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Schüler
- Deutsches Rotes Kreuz Kreisverband Hamburg Altona und Mitte e.V, Hamburg, Germany
| | - Klaus Püschel
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wiens K, Nisenbaum R, Sucha E, Aubry T, Farrell S, Palepu A, Duhoux A, Gadermann A, Hwang SW. Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness. Med Care 2021; 59:S110-S116. [PMID: 33710082 DOI: 10.1097/mlr.0000000000001379] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario. METHODS Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs. RESULTS Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2-4. CONCLUSIONS These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.
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Affiliation(s)
- Kathryn Wiens
- Dalla Lana School of Public Health, University of Toronto
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Rosane Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Ewa Sucha
- Institute for Clinical Evaluative Sciences
| | - Tim Aubry
- School of Psychology
- Centre for Research on Educational and Community Services, University of Ottawa
| | | | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- Division of General Internal Medicine, University of British Colombia, Vancouver, BC
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- School of Population and Public Health, University of British Colombia, Vancouver, BC
| | - Stephen W Hwang
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
- Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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59
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Facer BD, Bingham B, Fleisch SB, Walker JN, Ahmad M, Osmundson EC. Radiation Therapy Adherence Among Patients Experiencing Homelessness. Int J Radiat Oncol Biol Phys 2021; 109:1019-1027. [PMID: 33127492 DOI: 10.1016/j.ijrobp.2020.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiation therapy is a valuable, yet time- and resource-intense therapy. Patients experiencing homelessness (PEH) face many barriers related to the timely receipt of radiation therapy. Owing to a paucity of data regarding cancer treatment and homelessness, clinicians have a limited evidence base when recommending therapy to PEH. This study was performed to evaluate adherence to radiation therapy treatment regimens in PEH with cancer. METHODS AND MATERIALS The study cohort was primarily derived from the Vanderbilt University Medical Center Homeless Health Services program. Patients in the Homeless Health Services program with radiation oncology visits were identified by query of the electronic medical record. Manual chart review was performed to gather standard treatment parameters and data describing missed appointments. A comparison group of patients not experiencing homelessness (non-PEH) was generated by aggregating appointment data for all other patients receiving similar treatments at Vanderbilt University Medical Center during multiple, consecutive years. RESULTS In the study, 3408 PEH were identified, of whom 48 underwent radiation oncology consultation. Thirty-two were prescribed at least 1 course of radiation therapy, for a total of 54 unique courses. Out of these courses, 34 (62.9%) were completed as prescribed without delay, 12 (22.2%) were completed with delay(s), and 8 (14.8%) were not fully completed. Although the PEH cohort had significantly higher rates of delayed and undelivered fractions, the proportion of delayed or incomplete courses was not significantly different from the comparison group of non-PEH, particularly for courses with 10 or fewer fractions. Reasons for missed appointments for PEH were variable. CONCLUSIONS This is the first publication describing adherence to radiation therapy in PEH. Our data suggest that PEH are as likely as non-PEH to complete a course of radiation therapy, albeit with more treatment interruptions. When treatment courses of >10 fractions are expected, PEH may benefit from more hypofractionated regimens, provided they have equivalent clinical efficacy to longer regimens. Documenting reasons for missed appointments will be essential to further understanding the needs of PEH. This study serves as a foundation for further analysis regarding homelessness and radiation therapy.
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Affiliation(s)
- Benjin D Facer
- Vanderbilt University School of Medicine, Nashville, Tennessee; University of Texas Rio Grande Valley, Edinburg, Texas.
| | - Brian Bingham
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sheryl B Fleisch
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica N Walker
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mahmoud Ahmad
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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60
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McCarthy ML, Zheng Z, Wilder ME, Elmi A, Li Y, Zeger SL. The Influence of Social Determinants of Health on Emergency Departments Visits in a Medicaid Sample. Ann Emerg Med 2021; 77:511-522. [PMID: 33715829 DOI: 10.1016/j.annemergmed.2020.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE We evaluate the relationship between social determinants of health and emergency department (ED) visits in the Medicaid Cohort of the District of Columbia. METHODS We conducted a retrospective cohort analysis of 8,943 adult Medicaid beneficiaries who completed a social determinants of health survey at study enrollment. We merged the social determinants of health data with participants' Medicaid claims data for up to 24 months before enrollment. Using latent class analysis, we grouped our participants into 4 distinct social risk classes based on similar responses to the social determinants of health questions. We classified ED visits as primary care treatable or ED care needed, using the Minnesota algorithm. We calculated the adjusted log relative primary care treatable and ED care needed visit rates among the social risk classes by using generalized linear mixed-effects models. RESULTS The majority (71%) of the 49,111 ED visits made by the 8,943 participants were ED care needed. The adjusted log relative rate of both primary care treatable and ED care needed visit rates increased with each higher (worse) social risk class compared with the lowest class. Participants in the highest social risk class (ie, unemployed and many social risks) had a log relative primary care treatable and ED care needed rate of 39% (range 28% to 50%) and 29% (range 21% to 38%), respectively, adjusted for age, sex, and illness severity. CONCLUSION There is a strong relationship between social determinants of health and ED utilization in this Medicaid sample that is worth investigating in other Medicaid samples and patient populations.
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Affiliation(s)
- Melissa L McCarthy
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC.
| | - Zhaonian Zheng
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Marcee E Wilder
- Department of Emergency Medicine, George Washington University, Washington, DC; Medical Faculty Associates, Washington, DC
| | - Angelo Elmi
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Yixuan Li
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Scott L Zeger
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Gupta S, Xie E, Dong K. Treating homelessness as an emergency: learning from the COVID-19 response. CAN J EMERG MED 2021; 23:8-9. [PMID: 33683622 PMCID: PMC7829655 DOI: 10.1007/s43678-020-00051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/18/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Sahil Gupta
- Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada.
| | - Edward Xie
- Division of Emergency Medicine, University Health Network, Toronto, Canada
| | - Kathryn Dong
- Department of Emergency Medicine, University of Alberta, Edmonton, Canada
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Lech S, Schenk L, De la Torre Castro J, Schindel D. A retrospective analysis of the health and social situation of homeless people in Berlin: study protocol. Arch Public Health 2021; 79:28. [PMID: 33676557 PMCID: PMC7937212 DOI: 10.1186/s13690-021-00546-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Homelessness is often described as both a driver and a consequence of poor health, social exclusion and economic marginalisation. The present protocol provides a detailed description of the study Examining the health situation of homeless people in Berlin: a retrospective analysis of data from the health centre for the homeless of the Jenny De la Torre Foundation from 2006 to 2020 (GIG study). The primary objective of the GIG study is to describe and analyse the social and health situation of homeless people in Berlin. METHODS A retrospective secondary data analysis of an anonymous full census of medical records for the years 2006 until 2020 from a health centre for homeless people will be carried out. The main outcome is the description and analysis of the social and health situation of homeless people in Berlin. Total and cross-sectional sample characteristics will be presented in a descriptive analysis using Chi-Square Test, Mann-Whitney-U-Test or independent t-Test as appropriate to test (sub) group differences. Further, outcomes will be analysed using finite mixture modelling in order to distinguish different types of social and health conditions. Latent variable regressions will be applied in order to identify sociodemographic and disease-related factors associated with decreasing health conditions. DISCUSSION Given the high number of homeless individuals in Germany, it is of great importance to examine their social and health situation in order to gain a better understanding of challenges and needs of homeless people and work on new approaches and solutions to effectively address these. TRAIL REGISTRATION The study was prospectively registered with the German Clinical Trials Register (trial registration number: DRKS00021172 ). Registered 26 June 2020.
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Affiliation(s)
- Sonia Lech
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany.
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | | | - Daniel Schindel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
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Tsai J, Szymkowiak D, Kertesz SG. Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments. Am J Emerg Med 2021; 45:17-22. [PMID: 33647757 DOI: 10.1016/j.ajem.2021.02.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans. OBJECTIVE This study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity. DESIGN An observational study was conducted using national VA administrative data from 2016 to 2019. PARTICIPANTS Data on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed. MAIN MEASURES Homelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ). KEY RESULTS The most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22-24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans. CONCLUSIONS These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.
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Affiliation(s)
- Jack Tsai
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs Central Office, USA; School of Public Health, University of Texas Health Science Center at Houston, USA; Department of Psychiatry, Yale School of Medicine, USA.
| | - Dorota Szymkowiak
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs Central Office, USA
| | - Stefan G Kertesz
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs Central Office, USA; Birmingham Veterans Affairs Medical Center, USA; Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, USA
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Weerasinghe SS, Campbell SG. Identifying Acuity Level-Based Adult Emergency Department Use Time Trends Across Demographic Characteristics. Cureus 2021; 13:e13225. [PMID: 33728175 PMCID: PMC7946331 DOI: 10.7759/cureus.13225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Canadian emergency departments (EDs) are struggling under the weight of increased use by a growing population of elderly patients; those who lack proper housing; and those who lack family physicians to provide primary care. The Canadian Foundation for Healthcare Improvement projected a possible ED service utilization increase in Canada at a rate of 40% over three decades. This calls for local-level information on the time trends to understand demographic and temporal variations in the different geographical locations in the country. This study sought to identify and quantify acuity level-based per capita ED visit annual time trends for the 10-year period of 2006-2015 (by age, gender, and housing status). The aim is to provide detailed information on the time trends for demographically targeted ED planning locally. The lengthy record of data allows examining the changing directions in different time segments. Material and methods Administrative data from the largest emergency department in Halifax (Nova Scotia, Canada) was analyzed. Per capita adult ED visit rates (EDVR) based on Canadian Triage Acuity Scale (CTAS), age, gender, and housing status were analyzed. Trends in the age-gender-based standardized rates using 2011 census city population data were also estimated in order to account for the population increase in the city. Results No study in Canada has documented the possibility of flattening the escalating ED visit trend by maintaining an annual declining trend in low-acuity-level visits or documented a threshold rate of decline to be maintained. This study observed that the annual linear per capita non-homeless EDVR increment trend (328/year, CI:245-411, per 100,000) for all-acuity-level visits - noted for a ten-year period - would become stable when low-acuity-level CTAS4-5 visit declining trends (427/year, CI:350-503 and 121/year, CI:79-163, per 100,000) - noted for the period of 2012-2015 - were maintained at the same magnitude and direction. Alarming annual emergent (high acuity level of CTAS2) EDVR increase equivalent to 335/year (CI:280-391, per 100,000) was noted for all combined visits, from all age, gender, and housing groups visits. The highest incremental rate noted among above-50-year-olds (521/year, per 100,000, 95% CI:433-608) was neither driven by overall increasing population census numbers nor by increasing aging population numbers. We found statistically similar age-gender standardized rates (294/year, CI: 207-382) for all ED visits and (316/year, CI:261-372) for CTAS2 level visits, when adjusted for annual population increase. Homeless ED visits did not contribute to the overall ED visit incremental trend. The highest annual homeless increment rate was shown for <30-year-old group high acuity CTAS-2 level visits (219/year, CI:193-246, per 100,000). Conclusion Neither the city population increase nor increased homeless visits contributed to ED visit annual per capita incremental trends in the city of Halifax. The increasing trend was chiefly driven by high-acuity-level visits by >50-year-old patients. Our findings suggest one way to make this escalating ED visit rates stable in the future is by maintaining the declining semi-urgent and non-urgent visit trends at the same rates estimated within the years 2012-2015. These findings highlight the potential directions for ED services planning to keep up with the growing demand for high-acuity-level ED services by the aging population.
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Affiliation(s)
- Swarna S Weerasinghe
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, CAN
| | - Sam G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, CAN
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Fleury MJ, Grenier G, Sabetti J, Bertrand K, Clément M, Brochu S. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLoS One 2021; 16:e0245088. [PMID: 33444366 PMCID: PMC7808646 DOI: 10.1371/journal.pone.0245088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022] Open
Abstract
This study aimed to identify and compare major areas of met and unmet needs reported by 455 homeless or recently housed individuals recruited from emergency shelters, temporary housing, and permanent housing in Quebec (Canada). Mixed methods, guided by the Maslow framework, were used. Basic needs were the strongest needs category identified, followed by health and social services (an emergent category), and safety; very few participants expressed needs in the higher-order categories of love and belonging, self-esteem, and self-actualization. The only significant differences between the three housing groups occurred in basic needs met, which favored permanent housing residents. Safety was the only category where individuals reported more unmet than met needs. The study results suggested that increased overall access to and continuity of care with family physicians, MD or SUD clinicians and community organizations for social integration should be provided to help better these individuals. Case management, stigma prevention, supported employment programs, peer support and day centers should particularly be more widely implemented as interventions that may promote a higher incidence of met needs in specific needs categories.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
- Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada
- * E-mail:
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada
| | - Judith Sabetti
- Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada
- McGill University School of Social Work, Montreal, Quebec, Canada
| | - Karine Bertrand
- Département des Sciences de la Santé Communautaire, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michèle Clément
- Département de Médecine Sociale et Préventive, Université Laval, Quebec City, Quebec, Canada
| | - Serge Brochu
- Département de Criminologie, Université de Montréal, Montreal, Canada
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Rogers JH, Link AC, McCulloch D, Brandstetter E, Newman KL, Jackson ML, Hughes JP, Englund JA, Boeckh M, Sugg N, Ilcisin M, Sibley TR, Fay K, Lee J, Han P, Truong M, Richardson M, Nickerson DA, Starita LM, Bedford T, Chu HY. Characteristics of COVID-19 in Homeless Shelters : A Community-Based Surveillance Study. Ann Intern Med 2021; 174:42-49. [PMID: 32931328 PMCID: PMC7517131 DOI: 10.7326/m20-3799] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Homeless shelters are a high-risk setting for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission because of crowding and shared hygiene facilities. OBJECTIVE To investigate SARS-CoV-2 case counts across several adult and family homeless shelters in a major metropolitan area. DESIGN Cross-sectional, community-based surveillance study. (ClinicalTrials.gov: NCT04141917). SETTING 14 homeless shelters in King County, Washington. PARTICIPANTS A total of 1434 study encounters were done in shelter residents and staff, regardless of symptoms. INTERVENTION 2 strategies were used for SARS-CoV-2 testing: routine surveillance and contact tracing ("surge testing") events. MEASUREMENTS The primary outcome measure was test positivity rate of SARS-CoV-2 infection at shelters, determined by dividing the number of positive cases by the total number of participant encounters, regardless of symptoms. Sociodemographic, clinical, and virologic variables were assessed as correlates of viral positivity. RESULTS Among 1434 encounters, 29 (2% [95% CI, 1.4% to 2.9%]) cases of SARS-CoV-2 infection were detected across 5 shelters. Most (n = 21 [72.4%]) were detected during surge testing events rather than routine surveillance, and most (n = 21 [72.4% {CI, 52.8% to 87.3%}]) were asymptomatic at the time of sample collection. Persons who were positive for SARS-CoV-2 were more frequently aged 60 years or older than those without SARS-CoV-2 (44.8% vs. 15.9%). Eighty-six percent of persons with positive test results slept in a communal space rather than in a private or shared room. LIMITATION Selection bias due to voluntary participation and a relatively small case count. CONCLUSION Active surveillance and surge testing were used to detect multiple cases of asymptomatic and symptomatic SARS-CoV-2 infection in homeless shelters. The findings suggest an unmet need for routine viral testing outside of clinical settings for homeless populations. PRIMARY FUNDING SOURCE Gates Ventures.
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Affiliation(s)
- Julia H Rogers
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Amy C Link
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Denise McCulloch
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Elisabeth Brandstetter
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Kira L Newman
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (M.L.J.)
| | - James P Hughes
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Janet A Englund
- Seattle Children's Research Institute, University of Washington, Seattle, Washington (J.A.E.)
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Nancy Sugg
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Misja Ilcisin
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Thomas R Sibley
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Kairsten Fay
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Jover Lee
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Peter Han
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Melissa Truong
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Matthew Richardson
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Deborah A Nickerson
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Lea M Starita
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Trevor Bedford
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Helen Y Chu
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
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Wiens K, Rosella LC, Kurdyak P, Hwang SW. Patterns and predictors of high-cost users of the health system: a data linkage protocol to combine a cohort study and randomised controlled trial of adults with a history of homelessness. BMJ Open 2020; 10:e039966. [PMID: 33380481 PMCID: PMC7780507 DOI: 10.1136/bmjopen-2020-039966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Homelessness is a global issue with a detrimental impact on health. Individuals who experience homelessness are often labelled as frequent healthcare users; yet it is a small group of individuals who disproportionately use the majority of services. This protocol outlines the approach to combine survey data from a prospective cohort study and randomised controlled trial with administrative healthcare data to characterise patterns and predictors of healthcare utilisation among a group of adults with a history of homelessness. METHODS AND ANALYSIS This cohort study will apply survey data from the Health and Housing in Transition study and the At Home/Chez Soi study linked with administrative healthcare databases in Ontario, Canada. We will use count models to quantify the associations between baseline predisposing, enabling, and need factors and hospitalisations, emergency department visits and physician visits in the following year. Subsequently, we will identify individuals who are high-cost users of the health system (top 5%) and characterise their patterns of healthcare utilisation. Logistic regression will be applied to develop a set of models to predict who will be high-cost users over the next 5 years based on predisposing, enabling and need factors. Calibration and discrimination will be estimated with bootstrapped optimism (bootstrap performance-test performance) to ensure the model performance is not overestimated. ETHICS AND DISSEMINATION This study is approved by the St Michael's Hospital Research Ethics Board and the University of Toronto Research Ethics Board. Findings will be disseminated through publication in peer-reviewed journals, presentations at research conferences and brief reports made available to healthcare professionals and the general public. TRIAL REGISTRATION NUMBER This is a secondary data analysis of a cohort study and randomized trial. The At Home/Chez Soi study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.
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Affiliation(s)
- Kathryn Wiens
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Potter AJ, Wilking J, Nevarez H, Salinas S, Eisa R. Interventions for Health: Why and How Health Care Systems Provide Programs to Benefit Unhoused Patients. Popul Health Manag 2020; 23:445-452. [DOI: 10.1089/pop.2019.0217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew J. Potter
- Department of Political Science and Criminal Justice, California State University, Chico, Chico, California, USA
| | - Jennifer Wilking
- Department of Political Science and Criminal Justice, California State University, Chico, Chico, California, USA
| | - Holly Nevarez
- Department of Public Health and Health Administration, California State University, Chico, Chico, California, USA
| | - Stanley Salinas
- Department of Public Health and Health Administration, California State University, Chico, Chico, California, USA
| | - Reem Eisa
- Department of Political Science and Criminal Justice, California State University, Chico, Chico, California, USA
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Schreiter S, Fritz FD, Rössler W, Majić T, Schouler-Ocak M, Krausz MR, Bermpohl F, Gutwinski S. [Housing Situation Among People with Substance Use Disorder in a Psychiatric Centre in Berlin, Germany - A Cross-Sectional Patient Survey]. PSYCHIATRISCHE PRAXIS 2020; 48:156-160. [PMID: 33232977 DOI: 10.1055/a-1290-5091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the housing situation, service use and substance use among patients with substance use disorders seeking psychiatric treatment. METHODS Structured interview among 540 psychiatric inpatients including day clinics in a psychiatric centre in Berlin, Germany. RESULTS Patients under instable housing conditions were significantly more often diagnosed with a comorbid psychotic disorder and were significantly younger when first psychiatric or substance use treatment occurred, on average before onset of homelessness. CONCLUSION Homelessness among people with substance use disorder seeking psychiatric treatment is associated with disadvantageous treatment factors such as early age of psychiatric treatment and comorbid psychotic disorders. Therefore, addressing social difficulties especially after inpatient treatment and close cooperation between different care providers should be of high importance among these groups.
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Affiliation(s)
- Stefanie Schreiter
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Francesco Domenico Fritz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Wulf Rössler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Universität Zürich, Klinik für Psychiatrie und Psychotherapie, Zürich, Schweiz
| | - Tomislav Majić
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Deutschland
| | - Meryam Schouler-Ocak
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Deutschland
| | - Michael R Krausz
- Institute of Mental Health and Department of Psychiatry, University of British Columbia (UBC), Vancouver, Canada
| | - Felix Bermpohl
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Deutschland
| | - Stefan Gutwinski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Deutschland
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Abstract
Wohnungslosigkeit ist Ausdruck ausgeprägter sozialer Exklusionsphänomene und trifft besonders häufig Menschen mit seelischen Erkrankungen. Hierbei gehen die Erkrankungen meist der Wohnungslosigkeit vorweg, wobei einige seelische Störungen erst infolge der Wohnungslosigkeit auftreten. International wurde eine Vielzahl therapeutischer Unterstützungsformen für wohnungslose Menschen mit seelischen Erkrankungen evaluiert mit vorwiegend aufsuchenden Behandlungsstrategien. Dies wird häufig kombiniert mit niedrigschwelliger Zurverfügungstellung von Wohnraum. Hierbei zeigen sich gute Effekte auf die Zeit des Verbleibs in Wohnungen und auf die Verbesserung psychiatrischer Symptome, allerdings keine ausreichenden Effekte auf Substanzgebrauchsstörungen. Möglichkeiten zukünftiger Projekte liegen am ehesten im Einbezug ehemals Betroffener und in der Verwendung digitaler Medien.
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Affiliation(s)
- S Schreiter
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - S Gutwinski
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland.,Psychiatrische Universitätsklinik der Charité im St. Hedwig Krankenhaus, Berlin, Deutschland
| | - W Rössler
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Psychiatrische Universitätsklinik, Universität Zürich, Zürich, Schweiz
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71
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[Somatic diseases of homeless people in Germany. A narrative literature review for the years 2009-2019]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1189-1202. [PMID: 32940746 DOI: 10.1007/s00103-020-03213-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND According to estimates, between 337,000 and 650,000 people in Germany live without a permanent residence. They are highly deprived in terms of health. Studies on the health situation are rare and methodologically heterogeneous. Previous reviews have focused on mental illness. OBJECTIVES The aim of this paper is to provide an overview of current research on somatic diseases of homeless people in Germany. METHODS Based on a systematic literature review for the years 2009-2019, the methodological approaches, sample access, recruitment, and health aspects reported in the studies are compared. RESULTS By means of a systematic literature search, eight peer-reviewed journal articles were identified. Often the term "homelessness" was not operationalised. The average age of homeless participants was between 40.9 years and 67 years, and the proportion of women was between 0 and 35.3%. Frequently the sample was taken from accommodation and medical services for homeless people. One recruitment strategy was "respondent-driven sampling" in conjunction with incentives. The respondents most frequently reported cardiovascular diseases (17%-37.2%), musculoskeletal diseases (≥20%), and respiratory diseases (7%-24%). Depending on the recruitment site, infectious diseases were common (tuberculosis, hepatitis B and C). CONCLUSION Somatic health studies of homeless people are often selective. Older men with lower educational backgrounds living in large German cities appear to be overrepresented, and there is no uniform use of the term "homelessness." Compared with representative population data for Germany, increased risks of somatic illness were observed; cohort characteristics can explain these to a limited extent. Biographical and intersectional approaches are needed to capture multiple and cumulative exposure situations in homelessness.
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72
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Wong A, Chen J, Dicipulo R, Weiss D, Sleet DA, Francescutti LH. Combatting Homelessness in Canada: Applying Lessons Learned from Six Tiny Villages to the Edmonton Bridge Healing Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176279. [PMID: 32872284 PMCID: PMC7503437 DOI: 10.3390/ijerph17176279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022]
Abstract
Emerging evidence shows that homelessness continues to be a chronic public health problem throughout Canada. The Bridge Healing Program has been proposed in Edmonton, Alberta, as a novel approach to combat homelessness by using hospital emergency departments (ED) as a gateway to temporary housing. Building on the ideas of Tiny Villages, the Bridge Healing Program provides residents with immediate temporary housing before transitioning them to permanent homes. This paper aims to understand effective strategies that underlie the Tiny Villages concept by analyzing six case studies and applying the lessons learned to improving the Bridge Healing Program. After looking at six Tiny Villages, we identified four common elements of many successful Tiny Villages. These include a strong community, public support, funding with few restrictions, and affordable housing options post-graduation. The Bridge Healing Program emphasizes such key elements by having a strong team, numerous services, and connections to permanent housing. Furthermore, the Bridge Healing Program is unique in its ability to reduce repeat ED visits, lengths of stay in the ED, and healthcare costs. Overall, the Bridge Healing Program exhibits many traits associated with successful Tiny Villages and has the potential to address a gap in our current healthcare system.
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Affiliation(s)
- Anson Wong
- School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada; (A.W.); (J.C.); (R.D.)
| | - Jerry Chen
- School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada; (A.W.); (J.C.); (R.D.)
| | - Renée Dicipulo
- School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada; (A.W.); (J.C.); (R.D.)
| | - Danielle Weiss
- Northern Alberta Institute of Technology, Edmonton, AB T5G 2R1, Canada;
| | - David A. Sleet
- The Bizzell Group & School of Public Health, San Diego State University, San Diego, CA 92182, USA;
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73
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Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176254. [PMID: 32867382 PMCID: PMC7504688 DOI: 10.3390/ijerph17176254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 12/29/2022]
Abstract
Housing stability is a key outcome in studies evaluating housing services for the homeless population. Housing stability has typically been defined dichotomously and based on a fixed duration of maintenance in housing accommodations, which does not fully capture change in housing status among homeless individuals. Moreover, few typologies have examined housing trajectories across different housing types. Cluster analysis was used to develop a typology of housing status change for 270 currently or formerly homeless individuals in Quebec (Canada) residing in shelters and temporary and permanent housing. Participants were interviewed at baseline (T0) and 12 months later (T1). The Gelberg–Andersen Model was used to organize housing-related variables into predisposing, needs and enabling factors. Comparison analyses were conducted to assess group differences. Three groups (Groups 1, 3 and 4) had more favorable and two (Groups 2 and 5) less favorable, housing status at T1. Findings suggest that maintenance or improvement of housing status requires suitable types and frequencies of service use (enabling factors) that are well adapted to the nature and complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, should be prioritized for individuals at higher risk for returning to homelessness.
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74
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Panahpour Eslami N, Nguyen J, Navarro L, Douglas M, Bann M. Factors associated with low-acuity hospital admissions in a public safety-net setting: a cross-sectional study. BMC Health Serv Res 2020; 20:775. [PMID: 32838764 PMCID: PMC7446119 DOI: 10.1186/s12913-020-05456-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision. Methods Using an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized. Results A total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1–11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7–6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1–3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions). Conclusions Physician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.
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Affiliation(s)
| | | | | | | | - Maralyssa Bann
- Division of GIM/Hospital Medicine, Harborview Medical Center, 325 9th Avenue, Box 359780, Seattle, WA, 98104, USA. .,Department of Medicine, University of Washington School of Medicine, Seattle, USA.
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75
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Jenkinson J, Wheeler A, Wong C, Pires LM. Hospital Discharge Planning for People Experiencing Homelessness Leaving Acute Care: A Neglected Issue. Healthc Policy 2020; 16:14-21. [PMID: 32813636 PMCID: PMC7435079 DOI: 10.12927/hcpol.2020.26294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.
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Affiliation(s)
- Jesse Jenkinson
- PhD Candidate, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Adam Wheeler
- Barrister and Solicitor, Crown Counsel, Ministry of the Attorney General, Toronto, ON
| | - Claudia Wong
- Performance Improvement Specialist, Sunnybrook Health Sciences Centre, Toronto, ON
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76
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Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study. Public Health 2020; 185:224-231. [DOI: 10.1016/j.puhe.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
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77
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Vrouwe SQ, Johnson MB, Pham CH, Lane CJ, Garner WL, Gillenwater TJ, Yenikomshian HA. The Homelessness Crisis and Burn Injuries: A Cohort Study. J Burn Care Res 2020; 41:820-827. [PMID: 32619013 DOI: 10.1093/jbcr/iraa023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The United States is facing a growing homelessness crisis. We characterize the demographics and outcomes of homeless patients who sustain burn injury and compare them to a cohort of domiciled patients. A retrospective cohort study was performed at the Los Angeles County + University of Southern California Regional Burn Center for consecutive acute burn admissions in adults from June 1, 2015, to December 31, 2018. Patients were categorized as either domiciled or homeless at the time of their injury. Prevalence rates were estimated using data from the regional homeless count. From 881 admissions, 751 (85%) had stable housing and 130 (15%) were homeless. The rate of burn injury requiring hospitalization for homeless adults was estimated at 88 per 100,000 persons. Homeless patients had a significantly larger median burn size (7 vs 5%, P < .05) and a greater rate of flame burns (68 vs 42%, P < .001). For the homeless, rates of assault and self-inflicted injury were 4- (18 vs 4%, P < .001) and 2-fold higher (9 vs 4%, P < .001), respectively. Homeless patients had higher rates of mental illness (32 vs 12%, P < .001) and substance abuse (88 vs 22%, P < .001), and were less likely to follow-up as outpatients (54 vs 87%, P < .001). There was no difference in mortality. Homeless patients had a longer median length of stay (LOS; 11 vs 7 days, P < .001) without significant differences in LOS per percentage TBSA. Homeless individuals should be considered a high-risk population for burn injury. This distinction serves as a call to action for the development of burn prevention strategies.
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Affiliation(s)
- Sebastian Q Vrouwe
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
| | - Maxwell B Johnson
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
| | - Christopher H Pham
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
| | - Christianne J Lane
- Division of Biostatistics, University of Southern California, Los Angeles, California
| | - Warren L Garner
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
| | - T Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California
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78
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McCallum R, Medved MI, Hiebert-Murphy D, Distasio J, Sareen J, Chateau D. Fixed Nodes of Transience: Narratives of Homelessness and Emergency Department Use. QUALITATIVE HEALTH RESEARCH 2020; 30:1183-1195. [PMID: 31342845 DOI: 10.1177/1049732319862532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed.
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Affiliation(s)
| | - Maria I Medved
- University of Manitoba, Winnipeg, Manitoba, Canada
- The American University of Paris, Paris, France
| | | | - Jino Distasio
- The University of Winnipeg, Winnipeg, Manitoba, Canada
| | | | - Dan Chateau
- University of Manitoba, Winnipeg, Manitoba, Canada
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79
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Chu CMT, Moodie EEM, Streiner DL, Latimer EA. Trajectories of Homeless Shelter Utilization in the At Home/Chez Soi Trial of Housing First. Psychiatr Serv 2020; 71:648-655. [PMID: 32264800 DOI: 10.1176/appi.ps.201900260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Studies have shown that Housing First, a recovery-oriented housing intervention, is effective in reducing service utilization among homeless individuals with mental illness, but less is known about how Housing First affects patterns of service use over time and about characteristics associated with various utilization trajectories. This analysis aimed to explore latent class trajectories of shelter utilization in a randomized controlled trial of Housing First conducted across five Canadian cities. METHODS Data from the At Home/Chez Soi trial were analyzed (N=2,058). Latent class growth analysis was performed using days of shelter utilization to identify trajectories over 24 months. Multinomial logistic regression was used to determine which baseline variables, including treatment group, could predict class membership. RESULTS Four shelter use trajectories were identified: consistently low (N=1,631, 79%); mostly low (N=120, 6%); early temporary increase (N=179, 9%); and higher use, late temporary increase (N=128, 6%). Treatment group was a significant predictor of class membership. Those enrolled in Housing First had lower odds of experiencing higher shelter use trajectories (mostly low: odds ratio [OR]=0.50, 95% confidence interval [CI]=0.34-0.72; early temporary increase: OR=0.21, 95% CI=0.15-0.31; higher use, late temporary increase: OR=0.14, 95% CI=0.09-0.22). Other variables associated with trajectory classes included older age and longer time homeless, both of which were associated with higher shelter use. CONCLUSIONS Several participant characteristics were associated with different shelter use patterns. Knowledge of variables associated with more favorable trajectories may help to inform service planning and contribute to modeling efforts for homelessness.
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Affiliation(s)
- Cherry M T Chu
- Department of Epidemiology, Biostatistics, and Occupational Health (Chu, Moodie), and Department of Psychiatry (Latimer), McGill University, Montreal; Douglas Mental Health University Institute, Montreal (Chu, Latimer); Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada (Streiner)
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics, and Occupational Health (Chu, Moodie), and Department of Psychiatry (Latimer), McGill University, Montreal; Douglas Mental Health University Institute, Montreal (Chu, Latimer); Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada (Streiner)
| | - David L Streiner
- Department of Epidemiology, Biostatistics, and Occupational Health (Chu, Moodie), and Department of Psychiatry (Latimer), McGill University, Montreal; Douglas Mental Health University Institute, Montreal (Chu, Latimer); Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada (Streiner)
| | - Eric A Latimer
- Department of Epidemiology, Biostatistics, and Occupational Health (Chu, Moodie), and Department of Psychiatry (Latimer), McGill University, Montreal; Douglas Mental Health University Institute, Montreal (Chu, Latimer); Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada (Streiner)
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80
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Djuric CM, Vottero B. Primary care services tailored for adult and adolescent homeless persons: a scoping review protocol. JBI Evid Synth 2020; 18:2031-2037. [DOI: 10.11124/jbisrir-d-19-00331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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81
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Bring C, Kruse M, Ankarfeldt MZ, Brünés N, Pedersen M, Petersen J, Andersen O. Post-hospital medical respite care for homeless people in Denmark: a randomized controlled trial and cost-utility analysis. BMC Health Serv Res 2020; 20:508. [PMID: 32503545 PMCID: PMC7275557 DOI: 10.1186/s12913-020-05358-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 05/24/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Camilla Bring
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
| | - Marie Kruse
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.,Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Mikkel Z Ankarfeldt
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.,Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg hospital, Frederiksberg, Denmark
| | - Nina Brünés
- Patient Care, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Maja Pedersen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.,Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Janne Petersen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.,Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg hospital, Frederiksberg, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ove Andersen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.,Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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82
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Abstract
BACKGROUND National efforts are underway to reduce hospital readmissions. Few studies have used administrative data to provide a global view of readmission among people experiencing homelessness, who often utilize multiple hospital systems. OBJECTIVE To examine the 30-day hospital readmission rate and factors associated with readmission following discharge among homeless Medicaid members in Massachusetts. METHODS We analyzed medical record and Medicaid administrative data for 1269 hospitalizations between 2013 and 2014 for 458 unique patients attributed to Boston Health Care for the Homeless Program. Generalized Estimating Equations were used to investigate factors associated with readmission. RESULTS Of all hospitalizations, 27% resulted in readmission, more than double the average national Medicaid readmission rate. Leaving against medical advice was associated with increased readmission, while having a Health Care for the Homeless primary care practitioner was associated with reduced readmission. Among the most frequently admitted individuals, being discharged to medical respite care was associated with reduced readmission. CONCLUSIONS To break the readmission cycle, health care providers serving homeless individuals could focus on assuring access to medical respite care and extending outreach efforts that increase primary care engagement. This may be especially important for accountable care systems, as safety net providers increasingly assume financial risk for patients' total cost and quality of care.
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83
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Gadermann AM, Karim ME, Norena M, Emerson SD, Hubley AM, Russell LB, Nisenbaum R, Hwang SW, Aubry T, Palepu A. The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study. J Urban Health 2020; 97:239-249. [PMID: 32078728 PMCID: PMC7101457 DOI: 10.1007/s11524-019-00406-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.
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Affiliation(s)
- Anne M Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada.
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Mohammad Ehsanul Karim
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | | | - Anita M Hubley
- Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, Canada
| | - Lara B Russell
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Tim Aubry
- School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, Canada
| | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
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84
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Miller JP, O' Reilly GM, Mackelprang JL, Mitra B. Trauma in adults experiencing homelessness. Injury 2020; 51:897-905. [PMID: 32147144 DOI: 10.1016/j.injury.2020.02.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients. METHODS A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism. RESULTS Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09). CONCLUSION Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services.
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Affiliation(s)
| | - Gerard M O' Reilly
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | | | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
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85
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Gupta R, Ghaly M, Todoroff C, Wali S. Creating value for communities: Los Angeles County's investment in Housing for Health. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2020; 8:100387. [PMID: 32001247 DOI: 10.1016/j.hjdsi.2019.100387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 09/17/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
With U.S. healthcare expenditures leading and social service spending trailing other developed nations, patients, caregivers, and employers are insisting on improved value in health and healthcare for communities. Yet, health systems struggle to understand how to best invest existing funding or savings to reach these goals. We share the experience of Los Angeles County's health system that has invested in housing through their Housing for Health Program (HFH) to address the needs of high cost populations within communities. The approach rested on four key program strategies including having partnerships with various housing facilities, a whole person approach with broad community-based resources, a local footprint in community health services, and a robust jail and prison transitions program. HFH also relied on three key implementation strategies including having dynamic funding sources, stakeholder alignment, and continuous improvement. This case report describes these program and implementation strategies plus challenges and lessons learned navigating homeless individuals through the regulations of various funding contracts, maintaining service provider capacity, maintaining local culture in implementation, and persistent gaps in affordable housing availability. Future policies can incentivize similar efforts and infrastructure to transfer healthcare dollars into public services to improve housing and value for communities.
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Affiliation(s)
- Reshma Gupta
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; UCLA-Olive View Medical Center, Los Angeles County Department of Health Services, Los Angeles, CA, USA.
| | - Mark Ghaly
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Cheri Todoroff
- Housing for Health, Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Soma Wali
- UCLA-Olive View Medical Center, Los Angeles County Department of Health Services, Los Angeles, CA, USA
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86
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Kerman N, Aubry T, Adair CE, Distasio J, Latimer E, Somers J, Stergiopoulos V. Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 47:515-525. [DOI: 10.1007/s10488-020-01008-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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87
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Khan BM, Reid N, Brown R, Kozloff N, Stergiopoulos V. Engaging Adults Experiencing Homelessness in Recovery Education: A Qualitative Analysis of Individual and Program Level Enabling Factors. Front Psychiatry 2020; 11:779. [PMID: 32848944 PMCID: PMC7424067 DOI: 10.3389/fpsyt.2020.00779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/22/2020] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Recovery Education Centres (REC) in mental health offer a new model of providing recovery supports through emancipatory adult education and recovery-oriented service principles. Despite the widespread adoption of RECs, there is limited evidence regarding factors enabling engagement and participation, particularly for unique subpopulations or service delivery contexts. The Supporting Transitions and Recovery Learning Centre (STAR) in Toronto, Ontario is the first REC in Canada and one of few worldwide supporting adults transitioning out of homelessness. This research aimed to investigate individual and program level enablers of engagement and participation in a REC for this population. METHODS Qualitative methods were used to explore the experiences of 20 service user participants through semi-structured interviews exploring their experiences of REC participation and perceived key program features. Interviews were conducted between July 2017 and June 2018, six to 14 months following REC enrollment, and analyzed using inductive thematic analysis. RESULTS In contrast to past experiences with health and social services, participants described a welcoming and respectful physical and interpersonal environment with low-barrier seamless access facilitating their engagement and participation. Although the realities of homelessness presented barriers for some, participants described that the involvement of peers, as role models, and the self-directed, strengths, and skills-based curriculum, co-produced and co-delivered by peers and professionals, were instrumental in activating the process of recovery through education. CONCLUSIONS/IMPLICATIONS Findings are consistent with the growing evidence base of the defining features of RECs and suggest this model can be successfully extended to support recovery among adults transitioning out of homelessness. This unique examination of Canada's first REC for adults exiting homelessness can help guide program and policy development to better support this disadvantaged population.
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Affiliation(s)
- Bushra M Khan
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nadine Reid
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rebecca Brown
- Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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88
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Moore-Nadler M, Clanton C, Roussel L. Storytelling to Capture the Health Care Perspective of People Who Are Homeless. QUALITATIVE HEALTH RESEARCH 2020; 30:182-195. [PMID: 31274048 DOI: 10.1177/1049732319857058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Utilizing a hermeneutic philosophical approach, the researchers explored the perceptions and experiences of people who are homeless in Mobile, Alabama, receiving health care and interacting with health care providers. Using the voice of the participants, discussions among the researchers, and supporting literature reinforcing key concepts, a framework was created illustrating the lived experience. The following themes were identified: social determinants of health, compromised systems, professionalism, dehumanization, engagement, and downward trajectory. The experiences described and themes identified indicate a breakdown in therapeutic relationships between homeless individuals and health care providers, contributing to the continuing destabilization common in this population.
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Affiliation(s)
| | - Clista Clanton
- College of Nursing, University of South Alabama, Mobile, Alabama, USA
| | - Linda Roussel
- College of Nursing, Texas Woman's University, Denton, Texas, USA
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89
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Korczak V, Shanthosh J, Jan S, Dinh M, Lung T. Costs and effects of interventions targeting frequent presenters to the emergency department: a systematic and narrative review. BMC Emerg Med 2019; 19:83. [PMID: 31888508 PMCID: PMC6937921 DOI: 10.1186/s12873-019-0296-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
Background Previous systematic reviews have examined the effectiveness of interventions for frequent presenters to the Emergency Department (ED) but not the costs and cost-effectiveness of such interventions. Method A systematic literature review was conducted which screened the following databases: Pubmed, Medline, Embase, Cochrane and Econlit. An inclusion and exclusion criteria were developed following PRISMA guidelines. A narrative review methodology was adopted due to the heterogeneity of the reporting of the costs across the studies. Results One thousand three hundred eighty-nine papers were found and 16 were included in the review. All of the interventions were variations of a case management approach. Apart from one study which had mixed results, all of the papers reported a decrease in ED use and costs. There were no cost effectiveness studies. Conclusion The majority of interventions for frequent presenters to the ED were found to decrease ED use and cost. Future research should be undertaken to examine the cost effectiveness of these interventions.
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Affiliation(s)
- Viola Korczak
- The George Institute for Global Health, UNSW Sydney, Level 5/1 King St Newtown NSW, Sydney, 2042, Australia. .,Emergency Department, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Janani Shanthosh
- The George Institute for Global Health, UNSW Sydney, Level 5/1 King St Newtown NSW, Sydney, 2042, Australia.,The Australian Human Rights Institute, UNSW Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, UNSW Sydney, Level 5/1 King St Newtown NSW, Sydney, 2042, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Dinh
- Emergency Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Thomas Lung
- The George Institute for Global Health, UNSW Sydney, Level 5/1 King St Newtown NSW, Sydney, 2042, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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90
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Schreiter S, Heidrich S, Zulauf J, Saathoff U, Brückner A, Majic T, Rössler W, Schouler-Ocak M, Krausz MR, Bermpohl F, Bäuml J, Gutwinski S. Housing situation and healthcare for patients in a psychiatric centre in Berlin, Germany: a cross-sectional patient survey. BMJ Open 2019; 9:e032576. [PMID: 31888930 PMCID: PMC6937056 DOI: 10.1136/bmjopen-2019-032576] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To determine the housing situation among people seeking psychiatric treatment in relation to morbidity and service utilisation. DESIGN Cross-sectional patient survey. SETTING Psychiatric centre with a defined catchment area in Berlin, Germany, March-September 2016. PARTICIPANTS 540 psychiatric inpatients including day clinics (43.2% of all admitted patients in the study period (n=1251)). MAIN OUTCOME MEASURES Housing status 30 days prior the interview as well as influencing variables including service use, psychiatric morbidity and sociodemographic variables. RESULTS In our survey, 327 participants (68.7%) currently rented or owned an own apartment; 62 (13.0%) reported to be homeless (living on the street or in shelters for homeless or refugees); 87 (18.3%) were accommodated in sociotherapeutic facilities. Participants without an own apartment were more likely to be male and younger and to have a lower level of education. Homeless participants were diagnosed with a substance use disorder significantly more often (74.2%). Psychotic disorders were the highest among homeless participants (29.0%). Concerning service use, we did neither find a lower utilisation of ambulatory services nor a higher utilisation of hospital-based care among homeless participants. CONCLUSIONS Our findings underline the need for effective housing for people with mental illness. Despite many sociotherapeutic facilities, a concerning number of people with mental illness is living in homelessness. Especially early interventions addressing substance use might prevent future homelessness.
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Affiliation(s)
- Stefanie Schreiter
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sascha Heidrich
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jamie Zulauf
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ute Saathoff
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anne Brückner
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Tomislav Majic
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Germany
| | - Wulf Rössler
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Universität Zürich, Zurich, Switzerland
| | - Meryam Schouler-Ocak
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Germany
| | - Michael R Krausz
- Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Germany
| | - Josef Bäuml
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Germany
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91
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Adshead CD, Norman A, Holloway M. The inter-relationship between acquired brain injury, substance use and homelessness; the impact of adverse childhood experiences: an interpretative phenomenological analysis study. Disabil Rehabil 2019; 43:2411-2423. [PMID: 31825694 DOI: 10.1080/09638288.2019.1700565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Acquired Brain Injuries, caused by a range of illnesses and injuries, can lead to long-term difficulties for individuals; mental health problems, cognitive and executive impairment and psychosocial problems including relationship breakdown, substance abuse and potentially homelessness. The study aimed to seek and gain a more definitive understanding of the inter-relationship of Acquired Brain Injury, substance abuse and homelessness by identifying key themes associated with the inter-relationship between these variables. MATERIALS AND METHODS The study recruited eight participants through homeless organisations and treatment centres. Participants were screened for suitability (Brain Injury Screening Index; Drug Abuse Screening Tool; Alcohol Use Disorders Identification Test and then participated in recorded semi-structured interviews, transcribed and analysed using Interpretative Phenomenological Analysis. RESULTS The study identified five master themes: Adverse Childhood Experiences and Trauma; Mental Health; Cognitive Decline and Executive Function; Services; Relationships. CONCLUSION Healthcare professionals need to engage with children, their families, and adults, who have been exposed to adverse childhood experiences and should employ routine screening tools for brain injury to ensure their presence is factored into developing appropriate models of intervention.IMPLICATIONS FOR REHABILITATIONNeed person-centred approaches to intervention for those with acquired brain injury who are homeless and have substance abuse issues.Need to screen for the presence of acquired brain injury when engaging with individuals who are homeless or have substance abuse.Need screening of acquired brain injury and adverse childhood experiences to improve access to services post-brain injury.
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Affiliation(s)
| | - Alyson Norman
- School of Psychology, University of Plymouth, Plymouth, UK
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92
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Gabet M, Grenier G, Cao Z, Fleury MJ. Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4965. [PMID: 31817747 PMCID: PMC6950268 DOI: 10.3390/ijerph16244965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 11/22/2022]
Abstract
This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg-Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.
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Affiliation(s)
- Morgane Gabet
- Département de Gestion, Évaluation et Politiques de Santé, École de santé publique, Université de Montréal, 7101 av. du Parc, Montréal, QC H3X1X9, Canada;
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Guy Grenier
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Zhirong Cao
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Marie-Josée Fleury
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada
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93
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Shami E, Tabrizi JS, Nosratnejad S. The Effect of Health Insurance on the Utilization of Health Services: A Systematic Review and Meta-Analysis. Galen Med J 2019; 8:e1411. [PMID: 34466508 PMCID: PMC8343501 DOI: 10.31661/gmj.v8i0.1411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 12/16/2018] [Accepted: 01/18/2019] [Indexed: 11/27/2022] Open
Abstract
Insurance organizations are among the most influential organizations in the health system, which can lead to healthcare efficiency and patient satisfaction in case they are increasingly accessed. The main purpose of the present systematic review was to examine the effect of health insurance on the utilization of health services and also to examine the factors affecting it. The present study was a systematic review that aimed to examine the effect of health insurance on the utilization of health care services. The study was conducted in 2016 using Scopus, PubMed, Web of Science, Science Direct, and ProQuest databases. We examined the utilization rate of health insurance in insured people. The inclusion and exclusion criteria were included based on review and meta-analysis purposes. The utilization of health services increased for inpatient and outpatient services. The utilization rate of inpatient services increased by 0.51% whereas the utilization rate of outpatient services increased by 1.26%. We classified the variables affecting the utilization rate of insurance into three main categories and sub-categories: demographic variables of the household, socioeconomic status, and health status. Our study showed that insured people increased the utilization rate of health services, depending on the type of health services. Thus, health policymakers should consider the community's health insurance as a priority for health programs. For now, implementing universal health insurance is a good solution.
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Affiliation(s)
- Elham Shami
- Iranian Center of Excellence for Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Sadegh Tabrizi
- Department of Health Services Management, Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shirin Nosratnejad
- Iranian Center of Excellence for Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Iranian Center of Excellence in Health Services Management, Department of Health Management and Economics, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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94
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Richard L, Hwang SW, Forchuk C, Nisenbaum R, Clemens K, Wiens K, Booth R, Azimaee M, Shariff SZ. Validation study of health administrative data algorithms to identify individuals experiencing homelessness and estimate population prevalence of homelessness in Ontario, Canada. BMJ Open 2019; 9:e030221. [PMID: 31594882 PMCID: PMC6797366 DOI: 10.1136/bmjopen-2019-030221] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To validate case ascertainment algorithms for identifying individuals experiencing homelessness in health administrative databases between 2007 and 2014; and to estimate homelessness prevalence trends in Ontario, Canada, between 2007 and 2016. DESIGN A population-based retrospective validation study. SETTING Ontario, Canada, from 2007 to 2014 (validation) and 2007 to 2016 (estimation). PARTICIPANTS Our reference standard was the known housing status of a longitudinal cohort of housed (n=137 200) and homeless or vulnerably housed (n=686) individuals. Two reference standard definitions of homelessness were adopted: the housing episode and the annual housing experience (any homelessness within a calendar year). MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive values and positive likelihood ratios of 30 case ascertainment algorithms for detecting homelessness using up to eight health service databases. RESULTS Sensitivity estimates ranged from 10.8% to 28.9% (housing episode definition) and 18.5% to 35.6% (annual housing experience definition). Specificities exceeded 99% and positive likelihood ratios were high using both definitions. The most optimal algorithm estimates that 59 974 (95% CI 55 231 to 65 208) Ontarians (0.53% of the adult population) experienced homelessness in 2016, a 67.3% increase from 2007. CONCLUSIONS In Ontario, case ascertainment algorithms for identifying homelessness had low sensitivity but very high specificity and positive likelihood ratio. The use of health administrative databases may offer opportunities to track individuals experiencing homelessness over time and inform efforts to improve housing and health status in this vulnerable population.
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Affiliation(s)
| | | | - Cheryl Forchuk
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Rosane Nisenbaum
- St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kristin Clemens
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kathryn Wiens
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
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95
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Petit J, Loubiere S, Tinland A, Vargas-Moniz M, Spinnewijn F, Manning R, Santinello M, Wolf J, Bokszczanin A, Bernad R, Kallmen H, Ornelas J, Auquier P. European public perceptions of homelessness: A knowledge, attitudes and practices survey. PLoS One 2019; 14:e0221896. [PMID: 31553769 PMCID: PMC6760760 DOI: 10.1371/journal.pone.0221896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/16/2019] [Indexed: 11/18/2022] Open
Abstract
Background Addressing Citizen’s perspectives on homelessness is crucial for the design of effective and durable policy responses, and available research in Europe is not yet substantive. We aim to explore citizens’ opinions about homelessness and to explain the differences in attitudes within the general population of eight European countries: France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden. Methods A nationally representative telephone survey of European citizens was conducted in 2017. Three domains were investigated: Knowledge, Attitudes, and Practices about homelessness. Based on a multiple correspondence analysis (MCA), a generalized linear model for clustered and weighted samples was used to probe the associations between groups with opposing attitudes. Results Response rates ranged from 30.4% to 33.5% (N = 5,295). Most respondents (57%) had poor knowledge about homelessness. Respondents who thought the government spent too much on homelessness, people who are homeless should be responsible for housing, people remain homeless by choice, or homelessness keeps capabilities/empowerment intact (regarding meals, family contact, and access to work) clustered together (negative attitudes, 30%). Respondents who were willing to pay taxes, welcomed a shelter, or acknowledged people who are homeless may lack some capabilities (i.e. agreed on discrimination in hiring) made another cluster (positive attitudes, 58%). Respondents living in semi-urban or urban areas (ORs 1.33 and 1.34) and those engaged in practices to support people who are homeless (ORs > 1.4; p<0.005) were more likely to report positive attitudes, whereas those from France and Poland (p<0.001) were less likely to report positive attitudes. Conclusion The majority of European citizens hold positive attitudes towards people who are homeless, however there remain significant differences between and within countries. Although it is clear that there is strong support for increased government action and more effective solutions for Europe’s growing homelessness crisis, there also remain public opinion barriers rooted in enduring negative perceptions.
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Affiliation(s)
- Junie Petit
- Aix-Marseille University, School of Medicine—La Timone Medical Campus, CEReSS—Health Service Research and Quality of Life Center, Boulevard Jean Moulin, Marseille, France
| | - Sandrine Loubiere
- Aix-Marseille University, School of Medicine—La Timone Medical Campus, CEReSS—Health Service Research and Quality of Life Center, Boulevard Jean Moulin, Marseille, France
- Department of Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique—Hôpitaux de Marseille, Boulevard Jean Moulin, Marseille, France
- * E-mail:
| | - Aurlie Tinland
- Aix-Marseille University, School of Medicine—La Timone Medical Campus, CEReSS—Health Service Research and Quality of Life Center, Boulevard Jean Moulin, Marseille, France
- Department of Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique—Hôpitaux de Marseille, Boulevard Jean Moulin, Marseille, France
| | - Maria Vargas-Moniz
- APPsyCI (Applied Psychology Research Center: Capabilities and Inclusion), ISPA-Instituto Universitário, Rua Jardim do Tabaco, Lisbon, Portugal
| | - Freek Spinnewijn
- FEANTSA, European Federation of National Organisations Working with the Homeless, Chaussée de Louvain, Brussels, Belgium
| | - Rachel Manning
- Department of Psychology, University of Limerick, Limerick, Ireland
| | - Massimo Santinello
- Department of Developmental and Social Psychology, University of Padova, Via Venezia, Padova, Italy
| | - Judith Wolf
- Radboud University Medical Center, Radboud Institute for Health Sciences, Impuls—Netherlands Center for Social Care Research, Geert Grooteplein, EZ Nijmegen, The Netherlands
| | - Anna Bokszczanin
- Institute of Psychology, Opole University, Pl. Staszica, Opole, Poland
| | | | - Hakan Kallmen
- STAD, Stockholm Center for Psychiatry Research and Education, Karolinska Institutet, Norra Stati Onsgatan, Stockholm, Sweden
| | - Jose Ornelas
- APPsyCI (Applied Psychology Research Center: Capabilities and Inclusion), ISPA-Instituto Universitário, Rua Jardim do Tabaco, Lisbon, Portugal
| | - Pascal Auquier
- Aix-Marseille University, School of Medicine—La Timone Medical Campus, CEReSS—Health Service Research and Quality of Life Center, Boulevard Jean Moulin, Marseille, France
- Department of Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique—Hôpitaux de Marseille, Boulevard Jean Moulin, Marseille, France
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96
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Richler MJ, Yousaf S, Hwang SW, Dewhurst NF. Descriptive study of homeless patients' perceptions that affect medication adherence. Am J Health Syst Pharm 2019; 76:1288-1295. [PMID: 31418791 DOI: 10.1093/ajhp/zxz139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. METHODS A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. RESULTS Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. CONCLUSION In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.
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Affiliation(s)
- Matthew J Richler
- St. Michael's Hospital, Toronto, Canada, and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | - Stephen W Hwang
- St. Michael's Hospital, Toronto, Canada, and Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, Canada
| | - Norman F Dewhurst
- St. Michael's Hospital, Toronto, Canada, and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol 2019; 71:2585-2597. [PMID: 29852981 DOI: 10.1016/j.jacc.2018.02.077] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 01/14/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Samantha S Liauw
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
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98
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Sakai-Bizmark R, Chang RKR, Mena LA, Webber EJ, Marr EH, Kwong KY. Asthma Hospitalizations Among Homeless Children in New York State. Pediatrics 2019; 144:peds.2018-2769. [PMID: 31262776 PMCID: PMC6856786 DOI: 10.1542/peds.2018-2769] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma is widely prevalent among US children, particularly in homeless children, who often lack proper medication storage or the ability to avoid environmental triggers. In this study, we assess asthma-attributed health care use among homeless youth. We hypothesize that asthma hospitalization rates, symptom severity, and admission through the emergency department (ED) will be higher among homeless youth compared with nonhomeless youth. METHODS This secondary data analysis identified homeless and nonhomeless pediatric patients (<18 years old) with a primary diagnosis of asthma from New York statewide inpatient databases between 2009 and 2014. Hospitalization rate, readmission rate, admission through the ED, ventilation use, ICU admittance, hospitalization cost, and length of stay were measured. RESULTS We identified 71 837 asthma hospitalizations, yielding 73.8 and 2.3 hospitalizations per 1000 homeless and nonhomeless children, respectively. Hospitalization rates varied by nonhomeless income quartile, with low-income children experiencing higher rates (5.4) of hospitalization. Readmissions accounted for 16.0% of homeless and 12.5% of nonhomeless hospitalizations. Compared with nonhomeless patients, homeless patients were more likely to be admitted from the ED (odds ratio 1.96; 95% confidence interval: 1.82-2.12; P < .01), and among patients >5 years old, homeless patients were more likely to receive ventilation (odds ratio 1.45; 95% confidence interval: 1.01-2.09; P = .04). No significant differences were observed in ICU admittance, cost, or length of stay. CONCLUSIONS Homeless youth experience an asthma hospitalization rate 31 times higher than nonhomeless youth, with higher rates of readmission. Homeless youth live under uniquely challenging circumstances. Tailored asthma control strategies and educational intervention could greatly reduce hospitalizations.
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Affiliation(s)
- Rie Sakai-Bizmark
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California; .,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Ruey-Kang R. Chang
- Los Angeles Biomedical Research Institute,
Harbor-UCLA Medical Center, Torrance, California;,Department of Pediatrics, David Geffen School of
Medicine, University of California, Los Angeles, Los Angeles, California;
and
| | - Laurie A. Mena
- Los Angeles Biomedical Research Institute,
Harbor-UCLA Medical Center, Torrance, California
| | - Eliza J. Webber
- Los Angeles Biomedical Research Institute,
Harbor-UCLA Medical Center, Torrance, California
| | - Emily H. Marr
- Los Angeles Biomedical Research Institute,
Harbor-UCLA Medical Center, Torrance, California
| | - Kenny Y. Kwong
- Division of Allergy-Immunology, Department of
Pediatrics, Los Angeles County and University of Southern California Medical
Center, Los Angeles, California
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99
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Sease KK, Amati JB. "Housing First" for Optimal Child Health. Pediatrics 2019; 144:peds.2019-0500. [PMID: 31262777 DOI: 10.1542/peds.2019-0500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kerry K Sease
- Department of Pediatrics, School of Medicine Greenville, University of South Carolina, Greenville, South Carolina; and .,Prisma Health Children's Hospital-Midlands, Columbia, South Carolina
| | - J Blakely Amati
- Department of Pediatrics, School of Medicine Greenville, University of South Carolina, Greenville, South Carolina; and.,Prisma Health Children's Hospital-Midlands, Columbia, South Carolina
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100
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O'Carroll A, Wainwright D. Making sense of street chaos: an ethnographic exploration of homeless people's health service utilization. Int J Equity Health 2019; 18:113. [PMID: 31337407 PMCID: PMC6651952 DOI: 10.1186/s12939-019-1002-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 06/12/2019] [Indexed: 11/22/2022] Open
Abstract
Background Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population. Methods Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data. Results Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma. Conclusions An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.
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