Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA

The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review

INTRODUCTION

An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community.

METHODS

We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness.

RESULTS

A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement.

DISCUSSION

Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Racial/ethnic inequality in homelessness and drug overdose deaths in US States

PURPOSE

This study examined whether state-level racial disproportionality in homelessness is associated with racial disproportionality in overdose mortality.

METHODS

Counts of individuals experiencing homelessness (2015-2017; by state and racial/ethnic group) were obtained from the US Department of Housing and Urban Development; population estimates and counts of drug overdose deaths (2018-2021; by state and racial/ethnic group) were obtained from the National Center for Health Statistics. Homelessness and overdose mortality disproportionality scores were calculated to indicate the extent to which each racial group was over- or under- represented among those experiencing homelessness, or among overdose deaths, respectively (relative to each racial group's proportional share in the general population). For each racial group examined, ordinary least squares regression models with robust standard errors (SEs) examined associations between state-level disproportionality in homelessness and disproportionality in overdose mortality, adjusting for percent aged 18-64 and US Census Region, as well as disproportionality in educational attainment and unemployment.

RESULTS

State-level racial disproportionality in homelessness was significantly and positively associated with racial disproportionality in overdose mortality for Black (b = 0.16 [SE = 0.05]; p < .01), American Indian/Alaska Native (b = 0.71 [SE = 0.23]; p < .01), and Hispanic populations (b = 0.17 [SE = 0.05]; p < .01), in models adjusting for region and percent aged 18-64. The significant positive associations in these three populations persisted after adjusting for educational attainment disproportionality, yet the association was no longer significant in the Black population after adjusting for unemployment disproportionality.

CONCLUSION

States with the highest levels of racial/ethnic minority overrepresentation in homelessness generally also had relatively higher levels of racial/ethnic minority overrepresentation in overdose deaths.

Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness

BACKGROUND

Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH.

METHODS

This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs.

RESULTS

Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH.

CONCLUSIONS

PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.

Solving Homelessness in Delaware Requires Resolving the Disparities That Cause It

There are several paths to homelessness for adults and families, including a lack of affordable housing, financial crises such as unemployment, underemployment and low wages, and domestic violence. For youth, homelessness can be the result of running away from family conflict, family poverty, domestic violence, being put out of their homes, or loss of resources after aging out of state programs like foster care. The aim of this essay is to discuss the common paths to homelessness for adults, youth, and survivors of domestic violence as well as the associated health outcomes related to homelessness in relation to health equity and the social determinants of health. Additionally, this piece identifies existing disparities in homelessness, highlights Delaware resources, and seeks ways that Delaware can end involuntary homelessness in Delaware. Homelessness disproportionately affects minority populations more than other groups and has direct adverse health consequences on these populations. The poor health outcomes linked to homelessness can be many, co-occurring, and lifelong. If social determinants continue to be lacking, homelessness can become chronic. Homelessness is a prevalent public health issue in Delaware. With a health equity lens, state and community resources and solutions can be applied to help reduce homelessness and its disparities.