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Lee DU, Kwon J, Han J, Chang K, Kolachana S, Bahadur A, Lee KJ, Fan GH, Malik R. The Impact of Race and Sex on the Clinical Outcomes of Homeless Patients With Alcoholic Liver Disease: Propensity Score Matched Analysis of US Hospitals. J Clin Gastroenterol 2024; 58:708-717. [PMID: 37983807 PMCID: PMC11035492 DOI: 10.1097/mcg.0000000000001919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/27/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Among patients with alcoholic liver disease (ALD), homelessness poses significant medical and psychosocial risks; however, less is known about the effects of race and sex on the hospital outcomes of admitted homeless patients with ALD. METHODS The National Inpatient Sample database from 2012 to 2017 was used to isolate homeless patients with ALD, and the cohort was further stratified by race and sex for comparisons. Propensity score matching was utilized to minimize covariate confounding. The primary endpoints of this study include mortality, hospital length of stay, and hospital costs; secondary endpoints included the incidence of liver complications. RESULTS There were 3972 females/males postmatch, as well as 2224 Blacks/Whites and 4575 Hispanics/Whites postmatch. In multivariate, there were no significant differences observed in mortality rate, length of stay, and costs between sexes. Comparing liver outcomes, females had a higher incidence of hepatic encephalopathy [adjusted odds ratio (aOR) 1.02, 95% CI: 1.01-1.04, P <0.001]. In comparing Blacks versus Whites, Black patients had higher hospitalization costs (aOR 1.13, 95% CI: 1.03-1.24, P =0.01); however, there were no significant differences in mortality, length of stay, or liver complications. In comparing Hispanics versus Whites, Hispanic patients had longer length of hospital stay (aOR 1.12, 95% CI: 1.06-1.19, P <0.001), greater costs (aOR 1.15, 95% CI: 1.09-1.22, P <0.001), as well as higher prevalence of liver complications including varices (aOR 1.04, 95% CI: 1.02-1.06, P <0.001), hepatic encephalopathy (aOR 1.03, 95% CI: 1.02-1.04, P <0.001), and hepatorenal syndrome (aOR 1.01, 95% CI 1.00-1.01, P =0.03). However, there was no difference in mortality between White and Hispanic patients. CONCLUSIONS Black and Hispanic ALD patients experiencing homelessness were found to incur higher hospital charges; furthermore, Hispanic patients also had greater length of stay and higher incidence of liver-related complications compared with White counterparts.
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Affiliation(s)
- David U Lee
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD
| | - Jean Kwon
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - John Han
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - Kevin Chang
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - Sindhura Kolachana
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD
| | - Aneesh Bahadur
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - Ki Jung Lee
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - Gregory H Fan
- Division of Gastroenterology, Tufts Medical Center, Liver Center, Boston, MA
| | - Raza Malik
- Division of Gastroenterology, Albany Medical Center, Liver Center, Albany, NY
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Bien MB, Whitton A, Meehan A, Thornhill L, Ellis K, Leopold J, Borne D, Vickery KD, Imbert E, Twohey-Jacobs L, Perez KA, Mosites E. Strengthening Public Health Capacity to Address Infectious Diseases: Lessons From 3 Centers of Excellence in Public Health and Homelessness. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2023; 29:775-779. [PMID: 37738595 PMCID: PMC10552800 DOI: 10.1097/phh.0000000000001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
People experiencing homelessness are disproportionately affected by infectious diseases and often face barriers to receiving appropriate medical treatment. Responding to the needs of people experiencing homelessness requires state and local health departments to integrate information sources and coordinate multisector efforts. From 2021 to 2023, the CDC Foundation, in cooperation with the Centers for Disease Control and Prevention, established pilot Centers of Excellence in Public Health and Homelessness in Seattle, Washington; San Francisco, California; and the state of Minnesota. These centers strengthened their capacity to address the needs of people experiencing homelessness by supporting cross-sector partnerships, assessing the interoperability of data systems, prioritizing infectious disease needs, and identifying health disparities. These programs demonstrated that health departments are heterogeneous entities with differing resources and priorities. They also showed the importance of employing dedicated public health staff focused on homelessness, establishing diverse partnerships and the need for support from local leaders to address homelessness.
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Affiliation(s)
- Michael B. Bien
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Alaina Whitton
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Ashley Meehan
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Lee Thornhill
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Karin Ellis
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Josh Leopold
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Deborah Borne
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Katherine Diaz Vickery
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Elizabeth Imbert
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Lorraine Twohey-Jacobs
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Kenneth A. Perez
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
| | - Emily Mosites
- CDC Foundation, Atlanta, Georgia (Mr Bien and Ms Whitton); Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Meehan); Public Health Seattle and King County, Seattle, Washington (Mr Thornhill and Mss Ellis and Twohey-Jacobs); Minnesota Department of Health, St Paul, Minnesota (Mr Leopold); San Francisco Department of Public Health, San Francisco, California (Dr Borne); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota (Dr Vickery); Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, San Francisco, California (Dr Imbert); University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, California (Dr Imbert and Mr Perez); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Mosites)
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Salvalaggio G, Dong KA, Hyshka E, McCabe C, Nixon L, Rosychuk RJ, Dmitrienko K, Krajnak J, Mrklas K, Wild TC. Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study. Subst Abuse Treat Prev Policy 2022; 17:20. [PMID: 35279178 PMCID: PMC8917626 DOI: 10.1186/s13011-022-00445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay. Methods Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use). Results Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis. Conclusions After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s13011-022-00445-7.
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Adams EA, Parker J, Jablonski T, Kennedy J, Tasker F, Hunter D, Denham K, Smiles C, Muir C, O’Donnell A, Widnall E, Dotsikas K, Kaner E, Ramsay SE. A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063459. [PMID: 35329147 PMCID: PMC8950841 DOI: 10.3390/ijerph19063459] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 11/16/2022]
Abstract
People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.
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Affiliation(s)
- Emma A. Adams
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
- Correspondence:
| | - Jeff Parker
- HeathNow, Crisis, City House 1 City Road, Newcastle upon Tyne NE1 2AF, UK
- Pathway, 4th Floor East, 250 Euston Road, London NW1 2PG, UK
- Crisis Pie Team, 66 Commercial Street, London E1 6LT, UK
| | - Tony Jablonski
- HeathNow, Crisis, City House 1 City Road, Newcastle upon Tyne NE1 2AF, UK
- Pathway, 4th Floor East, 250 Euston Road, London NW1 2PG, UK
- Crisis Pie Team, 66 Commercial Street, London E1 6LT, UK
| | - Joanne Kennedy
- Expert by Experience Network, Fulfilling Lives Newcastle Gateshead, Gateshead NE8 4DY, UK
| | - Fiona Tasker
- Expert by Experience Network, Fulfilling Lives Newcastle Gateshead, Gateshead NE8 4DY, UK
| | - Desmond Hunter
- HeathNow, Crisis, City House 1 City Road, Newcastle upon Tyne NE1 2AF, UK
- Expert by Experience Network, Fulfilling Lives Newcastle Gateshead, Gateshead NE8 4DY, UK
| | - Katy Denham
- Newcastle University Medical School, Newcastle University, Newcastle upon Tyne NE2 4HH, UK;
| | - Claire Smiles
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
| | - Cassey Muir
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
| | - Amy O’Donnell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
| | - Emily Widnall
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK;
| | | | - Eileen Kaner
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
| | - Sheena E. Ramsay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; (C.S.); (C.M.); (A.O.); (E.K.); (S.E.R.)
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deRussy AJ, Jones AL, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Hoge AE, Kertesz SG. Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2021; 32:123-134. [PMID: 37234355 PMCID: PMC10208227 DOI: 10.1080/10530789.2021.2013013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/15/2021] [Accepted: 11/27/2021] [Indexed: 05/27/2023]
Abstract
Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.
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Affiliation(s)
| | - Audrey L Jones
- VA Salt Lake City Health Care System
- University of Utah School of Medicine
| | - Erika L Austin
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
| | - Adam J Gordon
- VA Salt Lake City Health Care System
- University of Utah School of Medicine
| | - Lillian Gelberg
- VA Greater Los Angeles Healthcare System
- University of California Los Angeles
| | - Sonya E Gabrielian
- VA Greater Los Angeles Healthcare System
- University of California Los Angeles
| | - Kevin R Riggs
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Medicine
| | - John R Blosnich
- VA Pittsburgh Healthcare System
- Suzanne Dworak-Peck School of Social Work, University of Southern California
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
| | | | - Allyson L Varley
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Medicine
| | | | - Stefan G Kertesz
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
- University of Alabama at Birmingham School of Medicine
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Alang S, Pando C, McClain M, Batts H, Letcher A, Hager J, Person T, Shaw A, Blake K, Matthews-Alvarado K. Survey of the Health of Urban Residents: a Community-Driven Assessment of Conditions Salient to the Health of Historically Excluded Populations in the USA. J Racial Ethn Health Disparities 2021; 8:953-972. [PMID: 32839897 PMCID: PMC7444865 DOI: 10.1007/s40615-020-00852-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Data from the Survey of the Health of Urban Residents (SHUR) identified connections between police brutality and medical mistrust, generating significant media, policy, and research attention. Amidst intersecting crises of COVID-19, racism, and police brutality, this report describes survey development and data collection procedures for the SHUR. BASIC PROCEDURES We conducted focus groups with Black men, Latinxs, and immigrants in Allentown, Pennsylvania. Findings were used to develop and refine measures of conditions salient to the health of urban residents across the country. Quota sampling was employed; oversampling people of color and persons whose usual source of care was not a doctor's office. MAIN FINDINGS Non-Hispanic Whites made up just under two thirds of the sample (63.65%, n = 2793). Black/African American respondents accounted for 14.2% of the sample (n = 623), while 11.62% (n = 510) were Latinx. Only 43.46% of respondents reported a doctor's office as their usual source of care. Novel measures of population-specific stressors include a range of negative encounters with the police, frequency of these encounters, and respondents' assessments of whether the encounters were necessary. SHUR assessed the likelihood of calling the police if there is a problem, worries about incarceration, and cause-specific stressors such as race-related impression management. PRINCIPAL CONCLUSIONS SHUR (n = 4389) is a useful resource for researchers seeking to address the health implications of experiences not frequently measured by national health surveillance surveys. It includes respondents' zip codes, presenting the opportunity to connect these data with zip code-level health system, social and economic characteristics that shape health beyond individual factors.
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Affiliation(s)
- Sirry Alang
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA.
| | - Cynthia Pando
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Malcolm McClain
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Greater Newark Conservancy, Newark, NJ, USA
| | - Hasshan Batts
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Abby Letcher
- Lehigh Valley Health Network, Allentown, PA, USA
- Neighborhood Health Centers of the Lehigh Valley, Allentown, PA, USA
| | - Janelle Hager
- Neighborhood Health Centers of the Lehigh Valley, Allentown, PA, USA
| | - Taylor Person
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Adama Shaw
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Digestive Care, Inc., Bethlehem, PA, USA
| | - Kwamaine Blake
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Kevelis Matthews-Alvarado
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
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7
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Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness. J Gen Intern Med 2021; 36:1944-1950. [PMID: 33515192 PMCID: PMC8298720 DOI: 10.1007/s11606-020-06483-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. OBJECTIVE To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. DESIGN This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. PARTICIPANTS Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. MAIN MEASURES Unplanned all-cause readmission to the study hospital within 90 days of discharge. KEY RESULTS Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). CONCLUSION Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.
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Siersbaek R, Ford JA, Burke S, Ní Cheallaigh C, Thomas S. Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review. BMJ Open 2021. [PMCID: PMC8039248 DOI: 10.1136/bmjopen-2020-043091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed. Design A realist review. Data sources Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019. Eligibility criteria for selecting studies The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes. Analysis Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory. Results Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention. Conclusions With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
| | | | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- Clinical Medicine, Trinity College Dublin School of Medicine, Dublin, Ireland
- General Medicine, St James's Hospital, Dublin, Ireland
| | - Steve Thomas
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
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9
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Siersbaek R, Ford J, Ní Cheallaigh C, Burke S, Thomas S. Making healthcare accessible for single adults with complex needs experiencing long-term homelessness: A realist evaluation protocol. HRB Open Res 2021; 3:73. [PMID: 33537554 PMCID: PMC7836031 DOI: 10.12688/hrbopenres.13154.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
| | - John Ford
- Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, CB2 0SR, UK
| | - Clíona Ní Cheallaigh
- Department of Clinical Medicine, Trinity College Dublin, Dublin 8, Dublin, D08 NHY1, Ireland
| | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
| | - Steve Thomas
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
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10
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Unmet Need for Medical Care: The Role of Mental Health Status. Community Ment Health J 2021; 57:121-127. [PMID: 32303934 DOI: 10.1007/s10597-020-00613-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/28/2020] [Indexed: 12/29/2022]
Abstract
Mental health status is an important factor to consider when exploring correlates of unmet need for medical care and prescription drugs. This paper explores whether self-rated mental health status is associated with unmet need and delays in obtaining medical care and prescription drugs. Descriptive statistics and multivariable logistic regression with 27,305 non-institutionalized adults aged 18 and older from the 2012 Medical Expenditure Panel Survey explore factors associated with self-reported unmet need for medical care and prescriptions, as well as access delays. Patients with lower physical and mental health status had the highest odds of experiencing unmet need for medical care and prescriptions, as well as access delays. These findings highlight the importance of increasing access to a usual source of care among individuals with lower self-rated mental health status as a strategy for addressing unmet need.
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11
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Siersbaek R, Ford J, Ní Cheallaigh C, Burke S, Thomas S. How accessible is healthcare for single adults experiencing long-term homelessness and complex needs? A realist evaluation protocol. HRB Open Res 2020; 3:73. [PMID: 33537554 PMCID: PMC7836031 DOI: 10.12688/hrbopenres.13154.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 04/01/2024] Open
Abstract
Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
| | - John Ford
- Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, CB2 0SR, UK
| | - Clíona Ní Cheallaigh
- Department of Clinical Medicine, Trinity College Dublin, Dublin 8, Dublin, D08 NHY1, Ireland
| | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
| | - Steve Thomas
- Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Dublin, Ireland
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12
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Khouitar SH, Simic S, Jevtovic Obradovic I, Janicijevic K. PUBLIC HEALTH SIGNIFICANCE OF UNFULFILLED HEALTH NEEDS OF THE POPULATION OF SERBIA. SANAMED 2020. [DOI: 10.24125/sanamed.v16i3.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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13
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Mitrasevic M, Radovanovic S, Radevic S, Maricic M, Macuzic IZ, Kanjevac T. The Unmet Healthcare Needs: Evidence from Serbia. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:1650-1658. [PMID: 33643939 PMCID: PMC7898096 DOI: 10.18502/ijph.v49i9.4081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background We aimed to determine the socio-economic factors associated with unmet healthcare needs of the population aged 20 and over in Serbia. Methods We used data from the 2013 National Health Survey (NHS) of the population of Serbia. We focused only on the data concerning the population aged 20 and over. The final sample thus included 13,765 participants. The logistic regression was used to examine the socio-economic factors associated with unmet health care needs. Results According to the data obtained in this study, 26.2% of the population aged 20 and over reported unmet health care needs during the previous 12 months. The multivariate analysis shows that significant indicators of unmet healthcare needs include: gender, age, marital status, level of education, financial and employment status. Conclusion Females, the elderly and those with the lowest levels of education and household income, as well as those who are divorced and unemployed are at highest risk of unmet healthcare needs. Different policies and approaches should be taken into consideration when it comes to vulnerable population groups in order to reduce the currently existing gaps to a minimum and provide more equal opportunities for health care to all citizens.
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Affiliation(s)
- Milos Mitrasevic
- Department for Organization, Planning, Evaluation and Medical Informatics, Clinical Center Kragujevac, Kragujevac, Serbia
| | - Snezana Radovanovic
- Department of Social Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Svetlana Radevic
- Department of Social Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Milena Maricic
- High Medical College of Professional Health Studies, Belgrade, Serbia
| | - Ivana Zivanović Macuzic
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Tatjana Kanjevac
- Department of Dentistry, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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14
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Dickins KA, Buchholz SW, Ingram D, Braun LT, Hamilton RJ, Earle M, Karnik NS. Supporting Primary Care Access and Use among Homeless Persons. SOCIAL WORK IN PUBLIC HEALTH 2020; 35:335-357. [PMID: 32865153 DOI: 10.1080/19371918.2020.1809589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.
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Affiliation(s)
- Kirsten A Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research , Boston, Massachusetts, USA
| | | | - Diana Ingram
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Lynne T Braun
- Rush University College of Nursing , Chicago, Illinois, USA
| | | | - Melinda Earle
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Niranjan S Karnik
- Rush Medical College Department of Psychiatry, Rush University College of Nursing , Chicago, Illinois, USA
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15
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Varley A, Montgomery AE, Steward J, Stringfellow E, Austin E, Gordon A, Pollio D, deRussy A, Hoge A, Gelberg L, Riggs K, Kim TW, Rubens SL, Kertesz S. Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations? QUALITATIVE HEALTH RESEARCH 2020; 30:865-879. [PMID: 31894725 PMCID: PMC9271358 DOI: 10.1177/1049732319895252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.
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Affiliation(s)
- Allyson Varley
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | - Erin Stringfellow
- Missouri Institute of Mental Health, University of Missouri, St. Louis
| | - Erika Austin
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | | | | | | | - Kevin Riggs
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | - Stefan Kertesz
- Birmingham VA Medical Center
- University of Alabama at Birmingham
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16
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Marcus R, Cha S, Sionean C, Kanny D. HIV Injection Risk Behaviors among HIV-Negative People Who Inject Drugs Experiencing Homelessness, 23 U.S. Cities. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2020; 1:10.1080/10530789.2021.1892931. [PMID: 34744406 PMCID: PMC8570172 DOI: 10.1080/10530789.2021.1892931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/08/2021] [Accepted: 02/14/2021] [Indexed: 06/13/2023]
Abstract
Despite recent declines in numbers of people who inject drugs (PWID) diagnosed with HIV, clusters of HIV among PWID are ongoing, especially among PWID experiencing homelessness. Using data from the National HIV Behavioral Surveillance in 2018, we evaluated the association between homelessness and injection risk and prevention behaviors among HIV-negative PWID who were recruited by respondent-driven sampling in 23 U.S. cities. Interviewers assessed sociodemographic characteristics, history of overdose, and behavioral risk and prevention factors for HIV. Adjusted prevalence ratios (aPR) and 95% CI were obtained using Poisson regression models. Of 10,614 HIV-negative PWID participants, 7275 (68.5%) reported experiencing homelessness. Homeless PWID were more likely than those who were not to be younger age, white, unemployed, without health insurance, in poverty, experiencing psychological distress, and incarcerated in the past 12 months. PWID experiencing homelessness were significantly more likely to report injection risk behaviors [share syringes/equipment (aPR = 1.26; 95% CI = 1.20-1.33), non-fatal opioid overdose (aPR = 1.64; 95% CI = 1.49-1.79)] and prevention behaviors [testing for HIV in past 12 months (aPR = 1.18; 95% CI = 1.12-1.24) and using syringe services programs (aPR = 1.09; 95% CI = 1.03-1.16)] than PWID not experiencing homelessness. Homelessness among PWID is associated with injection risk behaviors and non-fatal overdose.
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Affiliation(s)
- Ruthanne Marcus
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan Cha
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Catlainn Sionean
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Dafna Kanny
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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17
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Omerov P, Craftman ÅG, Mattsson E, Klarare A. Homeless persons' experiences of health- and social care: A systematic integrative review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:1-11. [PMID: 31524327 DOI: 10.1111/hsc.12857] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 05/22/2023]
Abstract
Homelessness is associated with high risks of morbidity and premature death. Many interventions aimed to improve physical and mental health exist, but do not reach the population of persons experiencing homelessness. Despite the widely reported unmet healthcare needs, more information about the barriers and facilitators that affect access to care for persons experiencing homelessness is needed. A systematic integrative review was performed to explore experiences and needs of health- and social care for persons experiencing homelessness. The following databases were searched: AMED, ASSIA, Academic Search Complete, CINAHL, Cochrane library, Nursing and Allied Database, PsycInfo, PubMed, Scopus and Web of Science Core Collection. Twenty-two studies met the inclusion criteria of empirical studies with adult persons experiencing homelessness, English language, and published 2008-2018. Fifty percent of the studies were of qualitative and quantitative design, respectively. Most studies (73%) were conducted in the United States (n=11) and Canada (n=5). The analysis resulted in three themes Unmet basic human needs, Interpersonal dimensions of access to care, and Structural and organizational aspects to meet needs. The findings highlight that persons in homelessness often must prioritize provision for basic human needs, such as finding shelter and food, over getting health- and social care. Bureaucracy and rigid opening hours, as well as discrimination and stigma, hinder these persons' access to health- and social care.
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Affiliation(s)
- Pernilla Omerov
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | | | - Elisabet Mattsson
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Department of Women's and Children's Health, Clinical Psychology in Healthcare, Uppsala University, Uppsala, Sweden
| | - Anna Klarare
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
- Department of Women's and Children's Health, Clinical Psychology in Healthcare, Uppsala University, Uppsala, Sweden
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18
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Parsell C, Clarke A, Vorsina M. Evidence for an integrated healthcare and psychosocial multidisciplinary model to address rough sleeping. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:34-41. [PMID: 31452354 DOI: 10.1111/hsc.12835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 06/10/2023]
Abstract
People who sleep rough/experience unsheltered homelessness face barriers accessing mainstream healthcare and psychosocial services. The barriers to service access exacerbate poor health, which in turn create additional challenges for rough sleepers to access health and psychosocial services, including stable housing. The study presents descriptive statistics to identify housing outcomes of people working with a Multidisciplinary Model that comprises integrated healthcare and psychosocial support, and qualitative data with clients and service providers to investigate how the Model is experienced and delivered in practice. Fieldwork was conducted between December 2016 and March 2018 with the Multidisciplinary Team operating in Cairns, in the far north of Australia. Qualitative data are drawn from in-depth interviews with 26 rough sleepers and 33 health and psychosocial service providers from the Multidisciplinary Team and the wider service system. Descriptive statistics show that 67% of clients who were sleeping rough were supported to immediately access stable housing, and at the end of the program, all clients remained housed. The qualitative findings illustrated how integrated healthcare and psychosocial outreach enabled people sleeping rough to overcome barriers they experienced accessing mainstream healthcare and other services. With the benefit of healthcare, people felt sufficiently well to engage with the psychosocial service providers to have their housing and other psychosocial needs addressed. This article demonstrates how individual responsibility for and control over healthcare is not only a matter of the individual, but also a matter requiring systems change and the active provision of resources to cater for the constraints and opportunities present in people's immediate environments.
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Affiliation(s)
| | - Andrew Clarke
- The University of Queensland, St Lucia, QLD, Australia
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19
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Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019; 19:974. [PMID: 31852493 PMCID: PMC6921587 DOI: 10.1186/s12913-019-4815-5] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Access to healthcare is a poorly defined construct, with insufficient understanding of differences in facilitators and barriers between US urban versus rural specialty care. We summarize recent literature and expand upon a prior conceptual access framework, adapted here specifically to urban and rural specialty care. Methods A systematic review was conducted of literature within the CINAHL, Medline, PubMed, PsycInfo, and ProQuest Social Sciences databases published between January 2013 and August 2018. Search terms targeted peer-reviewed academic publications pertinent to access to US urban or rural specialty healthcare. Exclusion criteria produced 67 articles. Findings were organized into an existing ten-dimension care access conceptual framework where possible, with additional topics grouped thematically into supplemental dimensions. Results Despite geographic and demographic differences, many access facilitators and barriers were common to both populations; only three dimensions did not contain literature addressing both urban and rural populations. The most commonly represented dimensions were availability and accommodation, appropriateness, and ability to perceive. Four new identified dimensions were: government and insurance policy, health organization and operations influence, stigma, and primary care and specialist influence. Conclusions While findings generally align with a preexisting framework, they also suggest several additional themes important to urban versus rural specialty care access.
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Affiliation(s)
- Melissa E Cyr
- School of Nursing, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Anna G Etchin
- VA Boston Healthcare System, 150 South Huntington Avenue, Jamaica Plain, MA, 02130, USA
| | - Barbara J Guthrie
- Bouvé College of Health Sciences, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - James C Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.
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20
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Blackwell JA, Rodgers JB, Franco RA, Cofield SS, Walter LA, Galbraith JW, Hess EP. Predictors of linkage to care for a nontargeted emergency department hepatitis C screening program. Am J Emerg Med 2019; 38:1396-1401. [PMID: 31836342 DOI: 10.1016/j.ajem.2019.11.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE We implemented a nontargeted, opt-out HCV testing and linkage to care (LTC) program in an academic tertiary care emergency department (ED). Despite research showing the critical role of ED-based HCV testing programs, predictors of LTC have not been defined for patients identified through the nontargeted ED testing strategy. In order to optimize health outcomes for patients with HCV, we sought to identify predictors of LTC failure. METHODS This was a retrospective cohort study of adult patients who were tested for HCV in the ED between August 2015 and September 2018 and were confirmed to have chronic HCV infection through RNA testing. We used logistic regression to assess the relationship between candidate predictors and the primary outcome, LTC failure, which was defined as a patient not being seen by an HCV treating provider after discharge from the ED. RESULTS Of 53,297 patients tested, 1,674 (3.1%) had HCV on confirmatory testing, and 355 (21%) linked to care. Predictors of LTC failure included younger age (OR 0.96, 95% CI 0.95-0.97), white race (OR 1.65, 95% CI 1.23-2.22), homelessness (OR 1.91, 95% CI 1.19-3.08), substance use (OR 1.77, 95% CI 1.34-2.34), and comorbid psychiatric illness (OR 2.16, 95% CI 1.59-2.94). Patients with significant medical comorbidities (OR 0.57, 95% CI 0.41-0.78) or HIV co-infection (OR 0.11, 95% CI 0.03-0.46) were less likely to experience LTC failure. CONCLUSIONS One in five HCV-infected patients identified by ED-based nontargeted testing successfully linked to an HCV treating provider. Predictors of LTC failure may guide the development of targeted interventions to improve LTC success.
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Affiliation(s)
- Joshua A Blackwell
- University of Alabama School of Medicine, 1670 University Blvd, Birmingham, AL 35233, USA; UAB School of Public Health, 1665 University Blvd, Birmingham, AL 35233, USA.
| | - Joel B Rodgers
- Department of Emergency Medicine, UAB School of Medicine, Old Hillman Building #251, 619 South 19th Street, Birmingham, AL 35249, USA
| | - Ricardo A Franco
- Division of Infectious Diseases, Department of Medicine, UAB School of Medicine, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA
| | - Stacey S Cofield
- Department of Biostatistics, University of Alabama at Birmingham, 1665 University Blvd #327, Birmingham, AL 35294, USA
| | - Lauren A Walter
- University of Alabama School of Medicine, 1670 University Blvd, Birmingham, AL 35233, USA; Department of Emergency Medicine, UAB School of Medicine, Old Hillman Building #251, 619 South 19th Street, Birmingham, AL 35249, USA
| | - James W Galbraith
- Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
| | - Erik P Hess
- University of Alabama School of Medicine, 1670 University Blvd, Birmingham, AL 35233, USA; Department of Emergency Medicine, UAB School of Medicine, Old Hillman Building #251, 619 South 19th Street, Birmingham, AL 35249, USA
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21
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White B, Ellis C, Jones W, Moran W, Simpson K. The effect of the global financial crisis on preventable hospitalizations among the homeless in New York State. J Health Serv Res Policy 2018; 23:80-86. [PMID: 29320892 DOI: 10.1177/1355819617742180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Periods of economic instability may increase preventable hospitalizations because of increased barriers to accessing primary care. For underserved populations such as the homeless, these barriers may be more pronounced due to limited resources in the health care safety net. This study examined the impact of the global financial crisis of 2007-2008 on access to care for the homeless in New York State. Methods Hospitalizations for ambulatory care sensitive conditions (ACSCs) were used as a proxy measure for primary care access. Admissions for ACSCs were identified in the New York State Inpatient Database from 2006 to 2012. Hospitalization rates for ACSCs were calculated for the homeless and nonhomeless. Multivariable linear regression was used to investigate the impact of the financial crisis on hospitalization rates for ACSCs. Results The findings indicate that during the financial crisis, homeless adults had significantly higher preventable hospitalizations than nonhomeless adults, and the uninsured homeless had significantly higher preventable hospitalizations when compared to other homeless subgroups. After the financial crisis, preventable hospitalizations for the homeless stabilized but remained at higher rates than those for the nonhomeless. Conclusions These findings are important to developing health policies designed to provide effective care for underserved population such as the homeless.
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Affiliation(s)
- Brandi White
- 1 Assistant Professor, Department of Clinical Sciences, College of Health Sciences, University of Kentucky, USA
| | - Charles Ellis
- 2 3627 Associate Professor, Communication Equity and Outcomes Laboratory, Department of Communication Sciences and Disorders, East Carolina University, USA
| | - Walter Jones
- 3 158156 Professor, Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, USA
| | - William Moran
- 4 158155 Professor and Director, Division of General Internal Medicine and Geriatrics, College of Medicine, Medical University of South Carolina, USA
| | - Kit Simpson
- 3 158156 Professor, Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, USA
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Zhang L, Norena M, Gadermann A, Hubley A, Russell L, Aubry T, To MJ, Farrell S, Hwang S, Palepu A. Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada. J Dual Diagn 2018; 14:21-31. [PMID: 29494795 DOI: 10.1080/15504263.2017.1392055] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study. METHODS In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months. RESULTS Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders. CONCLUSIONS Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.
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Affiliation(s)
- Linda Zhang
- a Division of General Internal Medicine , Department of Medicine, University of British Columbia , Vancouver , British Columbia , Canada
| | - Monica Norena
- b Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - Anne Gadermann
- b Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , British Columbia , Canada.,c School of Population and Public Health, University of British Columbia , Vancouver , British Columbia , Canada
| | - Anita Hubley
- d Department of Education Counselling Psychology and Special Education , University of British Columbia , Vancouver , British Columbia , Canada
| | - Lara Russell
- b Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - Tim Aubry
- e School of Psychology, University of Ottawa , Ottawa , Ontario , Canada
| | - Matthew J To
- f Centre for Urban Health Solutions, St. Michael's Hospital , Toronto , Ontario , Canada
| | - Susan Farrell
- g Royal Ottawa Health Care Group , Ottawa , Ontario , Canada
| | - Stephen Hwang
- f Centre for Urban Health Solutions, St. Michael's Hospital , Toronto , Ontario , Canada.,h Division of General Internal Medicine, Department of Medicine , University of Toronto , Toronto , Ontario , Canada
| | - Anita Palepu
- a Division of General Internal Medicine , Department of Medicine, University of British Columbia , Vancouver , British Columbia , Canada.,b Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , British Columbia , Canada
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Parsell C, ten Have C, Denton M, Walter Z. Self-management of health care: multimethod study of using integrated health care and supportive housing to address systematic barriers for people experiencing homelessness. AUST HEALTH REV 2018; 42:303-308. [DOI: 10.1071/ah16277] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
Abstract
Objectives The aims of the present study were to examine tenants’ experiences of a model of integrated health care and supportive housing and to identify whether integrated health care and supportive housing improved self-reported health and healthcare access. Methods The present study used a mixed-method survey design (n = 75) and qualitative interviews (n = 20) performed between September 2015 and August 2016. Participants were tenants of permanent supportive housing in Brisbane (Qld, Australia). Qualitative data were analysed thematically. Results Integrated health care and supportive housing were resources for tenants to overcome systematic barriers to accessing mainstream health care experienced when homeless. When homeless, people did not have access to resources required to maintain their health. Homelessness meant not having a voice to influence the health care people received; healthcare practitioners treated symptoms of poverty rather than considering how homelessness makes people sick. Integrated healthcare and supportive housing enabled tenants to receive treatment for health problems that were compounded by the barriers to accessing mainstream healthcare that homelessness represented. Conclusions Extending the evidence about housing as a social determinant of health, the present study shows that integrated health care and supportive housing enabled tenants to take control to self-manage their health care. In addition to homelessness directly contributing to ill health, the present study provides evidence of how the experience of homelessness contributes to exclusions from mainstream healthcare. What is known about the topic? People who are homeless experience poor physical and mental health, have unmet health care needs and use disproportionate rates of emergency health services. What does the paper add? The experience of homelessness creates barriers to accessing adequate health care. The provision of onsite multidisciplinary integrated health care in permanent supportive housing enabled illness self-management and greater control over lifestyle, and was associated with self-reported improved health and life satisfaction in formerly homeless tenants. What are the implications for practitioners? Integrated health care and supportive housing for the formerly homeless can improve self-reported health outcomes, enable healthier lifestyle choices and facilitate pathways into more appropriate and effective health care.
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Roche M, Duffield C, Smith J, Kelly D, Cook R, Bichel-Findlay J, Saunders C, Carter D. Nurse-led primary health care for homeless men: a multimethods descriptive study. Int Nurs Rev 2017; 65:392-399. [DOI: 10.1111/inr.12419] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M.A. Roche
- Mental Health Drug and Alcohol Nursing; Northern Sydney Local Health District & Australian Catholic University; Sydney NSW Australia
- Faculty of Health; University of Technology Sydney; Sydney NSW Australia
| | - C. Duffield
- Nursing & Health Services Management; University of Technology Sydney; Sydney NSW Australia
- Nursing & Health Services Management; Edith Cowan University; Western Australia
| | - J. Smith
- Primary Health Clinic; Matthew Talbot Hostel; St Vincent de Paul Society New South Wales; Woolloomooloo NSW Australia
| | - D. Kelly
- Support Services; St Vincent de Paul Society New South Wales; Australia
| | - R. Cook
- Centre for Health Services Management; University of Technology Sydney; Sydney NSW Australia
| | - J. Bichel-Findlay
- Digital Health and Innovation; Centre for Health Services Management; Faculty of Health; University of Technology Sydney; Sydney NSW Australia
| | - C. Saunders
- Centre for Health Services Management; Faculty of Health; University of Technology Sydney; Sydney NSW Australia
| | - D.J. Carter
- Faculty of Law; University of Technology Sydney; Sydney NSW Australia
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Van Straaten B, Rodenburg G, Van der Laan J, Boersma SN, Wolf JRLM, Van de Mheen D. Self-reported care needs of Dutch homeless people with and without a suspected intellectual disability: a 1.5-year follow-up study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:123-136. [PMID: 26427753 DOI: 10.1111/hsc.12287] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/30/2015] [Indexed: 05/26/2023]
Abstract
Cognitive impairment is a prevalent problem among the homeless and seems related to more psychosocial problems. However, little is known about the care needs of the subgroup of homeless people with an intellectual disability compared to those without an intellectual disability and how their care needs develop over time. This study explores self-reported care needs within a broad range of life domains among Dutch homeless people with and without a suspected intellectual disability to gain insight into the transition of self-reported care needs from baseline to follow-up in both subgroups. This longitudinal study is part of a cohort study among homeless people who had been accepted for an individual programme plan in four major Dutch cities. The initial cohort consisted of 513 participants who were interviewed in 2011. At 1.5-year follow-up, 336 participants (65.5%) were also interviewed and screened for intellectual disability. Of these participants, 31% (95% CI 26.2-36.1) had a suspected intellectual disability. For both groups, between baseline and follow-up, the number of 'unmet care needs' decreased significantly and the number of 'no care needs' increased significantly, while at follow-up, participants with a suspected intellectual disability reported 'no care needs' on significantly fewer life domains than those without a suspected intellectual disability (mean numbers 16.4 vs. 17.5). Between baseline and follow-up, 'met care needs' decreased significantly on housing for both groups, and increased on finances and dental care for participants with a suspected intellectual disability. At follow-up, participants with a suspected intellectual disability more often preferred housing support available by appointment than those without a suspected intellectual disability. These findings suggest that homeless people who had been accepted for an individual programme plan with a suspected intellectual disability have care needs for a longer period of time than those without a suspected intellectual disability. Providing care to homeless people with a suspected intellectual disability might require ongoing care and support, also after exiting homelessness. Support services should take this into account when considering their care provision and planning of services.
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Affiliation(s)
- Barbara Van Straaten
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
| | - Gerda Rodenburg
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
| | - Jorien Van der Laan
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
- Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Sandra N Boersma
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Judith R L M Wolf
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Dike Van de Mheen
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
- Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
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26
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Axon RN, Gebregziabher M, Dismuke CE, Hunt KJ, Yeager D, Ana EJS, Egede LE. Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. J Gen Intern Med 2016; 31:1331-1337. [PMID: 27418346 PMCID: PMC5071286 DOI: 10.1007/s11606-016-3786-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/21/2016] [Accepted: 06/15/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Veterans with evidence of homelessness have high rates of mental health and substance abuse disorders, but chronic medical conditions such as diabetes are also prevalent. OBJECTIVE We aimed to determine the impact of homelessness on glycemic control in patients with type 2 diabetes mellitus. DESIGN Longitudinal analysis of a retrospective cohort. SUBJECTS A national cohort of 1,263,906 Veterans with type 2 diabetes. Subjects with evidence of homelessness were identified using a combination of diagnostic and administrative codes. MAIN MEASURES Odds for poor glycemic control using hemoglobin A1C (HbA1C) cutoff values of 8 % and 9 %. Homeless defined as a score based on the number of indicator variables for homelessness within a veterans chart. KEY RESULTS Veterans with evidence of homelessness had a significantly greater annual mean HbA1C ≥ 8 (32.6 % vs. 20.43 %) and HbA1C ≥ 9 (21.4 % vs. 9.9 %), tended to be younger (58 vs. 67 years), were more likely to be non-Hispanic black (39.1 %), divorced (43 %) or never married (34 %), to be urban dwelling (88.8 %), and to have comorbid substance abuse (46.7 %), depression (42.3 %), psychoses (39.7 %), liver disease (18.8 %), and fluid/electrolyte disorders (20.4 %), relative to non-homeless veterans (all p < 0.0001). Homelessness was modeled as an ordinal variable that scored the number of times a homelessness indicator was found in the Veterans medical record. We observed a significant interaction between homelessness and race/ethnicity on the odds of poor glycemic control. Homelessness, across all racial-ethnic groups, was associated with increased odds of uncontrolled diabetes at a cut-point of 8 % and 9 % for hemoglobin A1C ; however, the magnitude of the association was greater in non-Hispanic whites [8 %, OR 1.55 (1.47;1.63)] and Hispanics [8 %, OR 2.11 (1.78;2.51)] than in non-Hispanic blacks [8 %, OR 1.22 (1.15;1.28)]. CONCLUSIONS Homelessness is a significant risk factor for uncontrolled diabetes in Veterans, especially among non-Hispanic white and Hispanic patients. While efforts to engage homeless patients in primary care services have had some success in recent years, these data suggest that broader efforts targeting management of diabetes and other chronic medical conditions remain warranted.
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Affiliation(s)
- R Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Clara E Dismuke
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Derik Yeager
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Elizabeth J Santa Ana
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Psychiatry, The Medical University of South Carolina, Charleston, SC, USA
| | - Leonard E Egede
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA.
- Center for Health Disparities Research Medical University of South Carolina, 135 Rutledge Avenue, MSC 593, Charleston, SC, 29425-0593, USA.
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Jaworsky D, Gadermann A, Duhoux A, Naismith TE, Norena M, To MJ, Hwang SW, Palepu A. Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada. J Urban Health 2016; 93:666-81. [PMID: 27457795 PMCID: PMC4987593 DOI: 10.1007/s11524-016-0065-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study examined the association of housing status over time with unmet physical health care needs and emergency department utilization among homeless and vulnerably housed persons in Canada. Homeless and vulnerably housed individuals completed interviewer-administered surveys on housing, unmet physical health care needs, health care utilization, sociodemographic characteristics, substance use, and health conditions at baseline and annually for 4 years. Generalized logistic mixed effects regression models examined the association of residential stability with unmet physical health care needs and emergency department utilization, adjusting for potential confounders. Participants were from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396). Residential stability was associated with lower odds of having unmet physical health needs (adjusted odds ratio (AOR), 0.82; 95 % confidence interval (CI), 0.67, 0.98) and emergency department utilization (AOR, 0.74; 95 % CI, 0.62, 0.88) over the 4-year follow-up period, after adjusting for potential confounders. Residential stability is associated with fewer unmet physical health care needs and lower emergency department utilization among homeless and vulnerably housed individuals. These findings highlight the need to address access to stable housing as a significant determinant of health disparities.
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Affiliation(s)
- Denise Jaworsky
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | - Trudy E Naismith
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Matthew J To
- Centre for Research in Inner City Health, St. Michael's Hospital, Toronto, ON, Canada
| | - Stephen W Hwang
- Centre for Research in Inner City Health, St. Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anita Palepu
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Zur J, Linton S, Mead H. Medical Respite and Linkages to Outpatient Health Care Providers among Individuals Experiencing Homelessness. J Community Health Nurs 2016; 33:81-9. [DOI: 10.1080/07370016.2016.1159439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Steward J, Holt CL, Pollio DE, Austin EL, Johnson N, Gordon AJ, Kertesz SG. Priorities in the primary care of persons experiencing homelessness: convergence and divergence in the views of patients and provider/experts. Patient Prefer Adherence 2016; 10:153-8. [PMID: 26929607 PMCID: PMC4760209 DOI: 10.2147/ppa.s75477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Homeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge. METHODS This qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26) were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10) were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity. RESULTS Both groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care more highly than provider/experts. CONCLUSION Accessibility and the perception of care based on medical evidence represent priority concerns for homeless patients and provider/experts. Patient control, a concept endorsed by experts, is not strongly endorsed by homeless patients. Understanding how to assure fluid communication, coordination, and team member cooperation could represent more worthy targets for research and quality improvement in this domain.
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Affiliation(s)
- Jocelyn Steward
- Department of Health Care Management, Clayton State University, Morrow, GA, USA
| | - Cheryl L Holt
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - David E Pollio
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erika L Austin
- Birmingham VA Medical Center, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - Nancy Johnson
- Birmingham VA Medical Center, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - Adam J Gordon
- VA Pittsburgh Health Care System, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stefan G Kertesz
- Birmingham VA Medical Center, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
- Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Correspondence: Stefan G Kertesz, Health Services Research and Development Program, Birmingham VA Medical Center, 700 South 19th Street, Birmingham, AL 35233, USA, Tel +1 205 996 2866, Fax +1 205 439 7248, Email
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Experience of primary care among homeless individuals with mental health conditions. PLoS One 2015; 10:e0117395. [PMID: 25659142 PMCID: PMC4319724 DOI: 10.1371/journal.pone.0117395] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/23/2014] [Indexed: 11/29/2022] Open
Abstract
The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons’ needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.
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Salem BE, Nyamathi Anp A, Reback C, Shoptaw S, Zhang S, Nudelman O. Unmet physical and mental healthcare needs among stimulant-using gay and bisexual homeless men. Issues Ment Health Nurs 2015; 36:685-92. [PMID: 26440871 PMCID: PMC4801108 DOI: 10.3109/01612840.2015.1021938] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this study was to gain a greater understanding of predictors of the unmet physical and mental healthcare needs of homeless, stimulant-using, gay and bisexual (G/B) men. This study correlated baseline self-reported unmet physical and mental healthcare needs among stimulant-using homeless G/B men (n = 422, 18-46 years of age). A structured questionnaire was administered at baseline and data were collected from October 2009 to January 2013. The study was approved by the University of California Human Subjects' Protection committee and the Friends Research Institute Human Research Protection Committee. Logistic regression revealed that those who self-reported ever being married, being in fair or poor health and in moderate-to-very severe pain, were more likely to experience unmet needs for physical health care. In terms of unmet mental health needs, those who self-reported moderate-to-very severe pain and/or those reporting having sex while high, were more likely to report unmet needs for mental health care. In contrast, those reporting receiving social support from others were less likely to have an unmet mental healthcare need. Research implications are discussed as they relate to access to healthcare needs among this vulnerable population.
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Affiliation(s)
| | | | - Cathy Reback
- b Friends Research Institute; University of California; Integrated Substance Abuse Programs and Semel Institute for Neuroscience and Human Behavior , Los Angeles , California , USA
| | - Steven Shoptaw
- c University of California , Los Angeles , California , USA
| | - Sheldon Zhang
- d San Diego State University , Los Angeles , California , USA
| | - Olga Nudelman
- a UCLA School of Nursing , Los Angeles , California , USA
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White BM, Newman SD. Access to Primary Care Services Among the Homeless. J Prim Care Community Health 2014; 6:77-87. [DOI: 10.1177/2150131914556122] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To identify barriers and facilitators to primary care access among the homeless using the Equity of Access to Medical Care Framework and to provide recommendations for medical and public health practitioners to improve health among this underserved population. Methods: A quasi-systematic review of the literature was conducted using the PubMed, CINAHL, and PsycINFO databases. Study elements from articles in the final analysis were extracted and categorized into dimensions of access from the Framework. Results: The review identified multiple barriers to primary care access for the homeless. This included lack of insurance coverage and competing priorities. Facilitators to access included tailored health care delivery systems and having a regular source of care. Conclusion: This review provides evidence that health policy initiatives, patient-centered care, and targeted interventions can assist with improving primary care access among the homeless.
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Development of the Primary Care Quality-Homeless (PCQ-H) instrument: a practical survey of homeless patients' experiences in primary care. Med Care 2014; 52:734-42. [PMID: 25023918 DOI: 10.1097/mlr.0000000000000160] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. OBJECTIVES This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients; and (b) the methods utilized in its development. METHODS Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function (TIF) curves to eliminate less informative items and devise plausibly distinct subscales. RESULTS The resulting 33-item instrument (Primary Care Quality-Homeless) has 4 subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items), and Homeless-specific Needs (4 items). Evidence for divergent and convergent validity is provided. TIF graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation, and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (α=0.75) and patients frequently reported problems in this aspect of care. CONCLUSIONS Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.
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