Impact of supportive housing on substance use–related health care utilization among homeless persons who are active substance users

Strategies to Reduce Frequent Emergency Department Use among Persons Experiencing Homelessness with Mental Health Conditions: a Scoping Review

The USA has some of the highest utilization rates of the Emergency Department (ED) worldwide, leading to increased healthcare costs, constrained resources, and fragmented care. Many of the highest ED utilizers are persons experiencing homelessness (PEH) and those with mental health conditions, with even higher use by those with comorbid social challenges. This study reviewed the literature assessing interventional approaches in the ED to minimize the burden of ED utilization by PEH with associated mental health conditions. We first conducted an informal literature review of high ED utilizers and their most common presenting symptoms. We then conducted a scoping review of articles according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines; we used PubMed and Web of Science databases as well as Google Scholar. We screened the titles and abstracts of studies that evaluated programs that aimed to reduce ED usage by patients with mental illness who were also experiencing homelessness. Of the 1574 titles and abstracts screened, 49 full texts were examined for eligibility. Of those, 35 articles were excluded for a final count of 14 included studies. We found that the studies fell under two main interventional categories: housing support and care management. There were various approaches to reduce ED visits from PEH with mental illness around the world. Overall, these studies found varying degrees of success in reducing ED visits for both housing intervention and care management strategies. Comparison of these studies reveals that the success of related strategies like housing support often have different outcomes which can be attributed to the differences between the populations studied, previously available community resources, and other psychosocial factors affecting study participants. Overall, the most successful studies found that a tailored approach that addresses the unique needs of participants had the greatest impact on reducing ED visits and hospitalizations. Further research is needed to determine the best strategies for specific populations and how to promote health equity among PEH with associated mental health conditions.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative study

Question

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders, in "real world" settings.

Goal

To determine sex disparities in non-medical opioid use (NMOU) at the end of outpatient medication-assisted treatment (MAT), using nationally representative data.

Design

Observational epidemiological study of publicly funded outpatient MAT programs in the national "Treatment episode data set-discharges" (TEDS-D) for 2019.

Participants

Persons aged ≥18 in their first treatment episode, in outpatient MAT for use of heroin or other opioids (N=11,549). The binary outcome was presence/absence of NMOU.

Results

In univariate analyses, males had significantly higher odds of NMOU, compared to females (odds ratio=1.27; Chi2 [df:1]=39.08; uncorrected p<0.0001; p=0.0041 after Bonferroni correction). A multivariable logistic regression detected a male>female odds ratio of 1.19 (95%CI=1.09-1.29; p<0.0001), adjusting for socio-demographic/clinical variables. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., at ages 18-29 and 30-39; corrected p=0.012, or if they used opioids by inhalation; corrected p=0.0041).

Conclusions

This nationally representative study indicates that males have greater odds of NMOU in their first episode of MAT, indicating more unfavorable outcomes. The study reveals specific socio-demographic and clinical variables under which this sex disparity is most prominent.

Injury Pattern Analysis to Optimize Burn Injury Prevention in the Unhoused Community

Unhoused patients are an overrepresented group in burn injury, and are a uniquely vulnerable population. Current research focuses on the consequences of homelessness on burn outcomes, with little known about the specific circumstances and behaviors leading to burn injury that may represent specific targets for injury prevention efforts. The burn registry at an urban regional burn center was queried for burn admissions in unhoused adults from 2019 to 2022. Registry data pulled included demographics, urine toxicology, mechanism of injury, and injury subjective history. Subjective injury history was reviewed to determine more specific injury circumstances and activities during which accidental burns occurred. Demographic and mechanistic trends in burn admissions were explored via descriptive statistics. Among 254 admissions for burns from the unhoused community, 58.1% of patients were positive for stimulants on admission. Among accidental injuries (69.7%), common circumstances included preparing food or beverages, cooking or using methamphetamine, smoking cannabis or tobacco, bonfires, and candles. A specific common circumstance was lighting a cigarette while handling accelerants (6.7%). Interventions for stimulant abuse, as well as outreach efforts to educate unhoused patients about situational awareness, safe handling of accelerants, safe smoking practices, and safe cooking practices, may be effective tools in reducing burn admissions in this vulnerable population.

Health Care of People Experiencing Homelessness: Part II

Health Care of People Experiencing HomelessnessIn this second part of a two-part review of health care for people experiencing homelessness, Taylor and Munson discuss approaches to care that are tailored to this population.

Evaluation of New York/New York III permanent supportive housing program

In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007-2017) from the NY/NY III evaluation team, to analyze this program's impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States

BACKGROUND

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement.

METHODS

Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates.

RESULTS

There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates.

CONCLUSIONS

Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area

BACKGROUND

Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited.

METHODS

We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data.

RESULTS

Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use.

CONCLUSIONS

Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection

BACKGROUND

Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection.

METHODS

We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility.

RESULTS

We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years.

CONCLUSIONS

Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.

Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review

BACKGROUND

Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization.

OBJECTIVES

To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research.

RESEARCH DESIGN

A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population.

SUBJECTS

Adults with substance use or SUDs, including alcohol use.

MEASURES

Hospital and emergency department utilization.

RESULTS

Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31).

CONCLUSIONS

Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.

The association between social needs and chronic conditions in a large, urban primary care population

There is consensus that social needs influence health outcomes, but less is known about the relationships between certain needs and chronic health conditions in large, diverse populations. This study sought to understand the association between social needs and specific chronic conditions using social needs screening and clinical data from Electronic Health Records. Between April 2018-December 2019, 33,550 adult (≥18y) patients completed a 10-item social needs screener during primary care visits in Bronx and Westchester counties, NY. Generalized linear models were used to estimate prevalence ratios for eight outcomes by number and type of needs with analyses completed in Summer 2020. There was a positive, cumulative association between social needs and each of the outcomes. The relationship was strongest for elevated PHQ-2, depression, alcohol/drug use disorder, and smoking. Those with ≥3 social needs were 3.90 times more likely to have an elevated PHQ-2 than those without needs (95% CI: 3.66, 4.16). Challenges with healthcare transportation was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. For example, those with transportation needs were 84% more likely to have an alcohol/drug use disorder diagnosis (95% CI: 1.59, 2.13) and 41% more likely to smoke (95% CI: 1.25, 1.58). Specific social needs may influence clinical issues in distinct ways. These findings suggest that health systems need to develop strategies that address unmet social need in order to optimize health outcomes, particularly in communities with a dual burden of poverty and chronic disease.

National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness

OBJECTIVE

People experiencing homelessness (PEH) have high rates of substance use, and homelessness may be an important driver of health disparities in the opioid overdose epidemic. However, few studies focus on homelessness among the opioid use disorder (OUD) treatment population. We examine national-level trends in substance use treatment admissions among PEH with OUD.

METHODS

This study used data from first-time treatment admissions in the United States from the Treatment Episode Data Set: Admissions (TEDS-A) to examine characteristics and trends of adults experiencing homelessness who entered state-licensed substance use treatment programs for OUD from 2013 to 2017. We used chi-squared analyses to examine changes in characteristics of this population over time and logistic regression to assess characteristics associated with receipt of medications for opioid use disorder (MOUD) among PEH.

RESULTS

Among all adults with OUD entering specialty treatment from 2013 to 2017, 12.5% reported experiencing homelessness. Compared to individuals not experiencing homelessness, PEH were more likely to be male, inject opioids, use cocaine or methamphetamine, and enter into residential detoxification treatment. PEH were less likely to enter outpatient treatment or receive MOUD. From 2013 to 2017, significant increases occurred in the proportion of PEH who had co-occurring psychiatric problems and used methamphetamines. Over time, treatment type shifted significantly from residential detoxification to outpatient treatment. Receipt of MOUD increased among PEH over time (13.7% to 25.2%), but lagged behind increases among individuals not experiencing homelessness. Among PEH, being older was associated with receiving MOUD, while concurrent methamphetamine use [adjusted odds ratio (AOR) 0.63; 95% CI 0.58, 0.69] and living in the southern United States (AOR 0.27; 95% CI 0.25, 0.30) were associated with not receiving MOUD.

DISCUSSION

The proportion of PEH with OUD who receive medications as part of treatment increased over time, but three quarters of PEH entering treatment still do not receive this highest standard in evidence-based care. The sharp increase observed in concomitant methamphetamine use in this population is concerning and has implications for treatment.

Increases in social support co-occur with decreases in depressive symptoms and substance use problems among adults in permanent supportive housing: an 18-month longitudinal study

BACKGROUND

Social support is a well-known protective factor against depressive symptoms and substance use problems, but very few studies have examined its protective effects among residents of permanent supportive housing (PSH), a housing program for people with a history of chronic homelessness. We utilized unconditional latent growth curve models (LGCMs) and parallel process growth models to describe univariate trajectories of social support, depressive symptoms, and substance use problems and to examine their longitudinal associations in a large sample of adults residing in PSH.

METHODS

Participants were 653 adult PSH residents in North Texas (56% female; 57% Black; mean age: 51 years) who participated in a monthly health coaching program from 2014 to 2017. Their health behaviors were assessed at baseline and tracked every six months at three follow-up visits.

RESULTS

Unconditional LGCMs indicated that over time, social support increased, whereas depressive symptoms and substance use problems decreased. However, their rates of change slowed over time. Further, in parallel process growth models, we found that at baseline, individuals with greater social support tended to have less severe depressive symptoms and substance use problems (coefficients: - 0.67, p < 0.01; - 0.52, p < 0.01, respectively). Individuals with a faster increase in social support tended to have steeper rates of reduction in both depressive symptoms (coefficient: - 0.99, p < 0.01) and substance use problems (coefficient: - 0.98, p < 0.01), respectively.

CONCLUSIONS

This study suggests that plausibly, increases in social support, though slowing over time, still positively impact depressive symptoms and substance use problems among PSH residents. Future PSH programs could emphasize social support as an early component as it may contribute to clients' overall health.

Engineering Approaches for Addressing Opioid Use Disorder in the Community

Many communities in the United States are struggling to deal with the negative consequences of illicit opioid use. Effectively addressing this epidemic requires the coordination and support of community stakeholders in a change process with common goals and objectives, continuous engagement with individuals with opioid use disorder (OUD) through their treatment and recovery journeys, application of systems engineering principles to drive process change and sustain it, and use of a formal evaluation process to support a learning community that continuously adapts. This review presents strategies to improve OUD treatment and recovery with a focus on engineering approaches grounded in systems thinking.