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Fischer FS, Shahzad H, Khan SN, Quatman CE. Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation. OTA Int 2024; 7:e335. [PMID: 38757142 PMCID: PMC11098169 DOI: 10.1097/oi9.0000000000000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 05/18/2024]
Abstract
Objectives To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. Design Retrospective cohort study. Setting Mariner claims database. Patients/Participants Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. Intervention Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. Main Outcome Measures One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. Results Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41). Conclusions Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. Level of Evidence Prognostic Level III.
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Affiliation(s)
- Fielding S. Fischer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Hania Shahzad
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Safdar N. Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Carmen E. Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
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Ball MAZ, Sack DE, Druffner SA, Jones I, Wrenn JO, Sexton MM, Shinn M, Hess JJ. Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED. JAMA Netw Open 2024; 7:e248565. [PMID: 38669017 PMCID: PMC11053378 DOI: 10.1001/jamanetworkopen.2024.8565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/28/2024] [Indexed: 04/29/2024] Open
Abstract
Importance Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness. Objective To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization. Design, Setting, and Participants This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023. Main Outcomes and Measures The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization. Results Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results. Conclusions and Relevance In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.
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Affiliation(s)
| | - Daniel E. Sack
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, University of Pennsylvania, Philadelphia
| | | | - Ian Jones
- Department of Emergency Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse O. Wrenn
- Department of Emergency Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mitchell M. Sexton
- Department of Emergency Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marybeth Shinn
- Vanderbilt University Peabody College, Nashville, Tennessee
| | - Jennifer J. Hess
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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3
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Ganguly AP, Alvarez KS, Mathew SR, Soni V, Vadlamani S, Balasubramanian BA, Bhavan KP. Intersecting social determinants of health among patients with childcare needs: a cross-sectional analysis of social vulnerability. BMC Public Health 2024; 24:639. [PMID: 38424507 PMCID: PMC10902938 DOI: 10.1186/s12889-024-18168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Access to childcare is an understudied social determinant of health (SDOH). Our health system established a childcare facility for patients to address childcare barriers to healthcare. Recognizing that social risk factors often co-exist, we sought to understand intersecting social risk factors among patients with childcare needs who utilized and did not utilize the childcare facility and identify residual unmet social needs alongside childcare needs. METHODS We conducted a cross-sectional analysis of patients who enrolled in the childcare facility from November 2020 to October 2022 to compare parameters of the Social Vulnerability Index (SVI) associated with the census tract extracted from electronic medical record (EMR) data among utilizers and non-utilizers of the facility. Overall SVI and segmentation into four themes of vulnerability (socioeconomic status, household characteristics, racial/ethnic minority status, and housing type/transportation) were compared across utilizers and utilizers. Number of 90th percentile indicators were also compared to assess extreme levels of vulnerability. A sample of utilizers additionally received a patient-reported social needs screening questionnaire administered at the childcare facility. RESULTS Among 400 enrollees in the childcare facility, 70% utilized childcare services and 30% did not. Utilizers and non-utilizers were demographically similar, though utilizers were more likely to speak Spanish (34%) compared to non-utilizers (22%). Mean SVI was similar among utilizers and non-utilizers, but the mean number of 90th percentile indicators were higher for non-utilizers compared to utilizers (4.3 ± 2.7 vs 3.7 ± 2.7, p = 0.03), primarily driven by differences in the housing type/transportation theme (p = 0.01). Non-utilizers had a lower rate of healthcare utilization compared to utilizers (p = 0.02). Among utilizers who received patient-reported screening, 84% had one unmet social need identified, of whom 62% agreed for additional assistance. Among social work referrals, 44% were linked to social workers in their medical clinics, while 56% were supported by social work integrated in the childcare facility. CONCLUSIONS This analysis of SDOH approximated by SVI showed actionable differences, potentially transportation barriers, among patients with childcare needs who utilized a health system-integrated childcare facility and patients who did not utilize services. Furthermore, residual unmet social needs among patients who utilized the facility demonstrate the multifactorial nature of social risk factors experienced by patients with childcare needs and opportunities to address intersecting social needs within an integrated intervention. Intersecting social needs require holistic examination and multifaceted interventions.
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Affiliation(s)
- Anisha P Ganguly
- Center of Innovation and Value, Parkland Health, Dallas, TX, USA.
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Health Equity Fellow, Parkland Health, 5200 Harry Hines Blvd, Dallas, TX, 75235, USA.
| | | | - Sheryl R Mathew
- Center of Innovation and Value, Parkland Health, Dallas, TX, USA
| | - Virali Soni
- Center of Innovation and Value, Parkland Health, Dallas, TX, USA
| | - Suman Vadlamani
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
- Institute for Implementation Science, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Kavita P Bhavan
- Center of Innovation and Value, Parkland Health, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Wu S, Ta L, Vieira J, Schwartz K, Perez J, Zeien J, Li D, Hartmark-Hill J. Adverse Childhood Experiences and Depression among Homeless Young Adults: A Social Determinants of Health Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:81. [PMID: 38248544 PMCID: PMC10815729 DOI: 10.3390/ijerph21010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.
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Affiliation(s)
- Shiyou Wu
- School of Social Work, Arizona State University, Phoenix, AZ 85004, USA
| | - Lac Ta
- College of Medicine–Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (L.T.); (J.V.); (K.S.); (J.P.); (J.H.-H.)
| | - Jaime Vieira
- College of Medicine–Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (L.T.); (J.V.); (K.S.); (J.P.); (J.H.-H.)
| | - Kendall Schwartz
- College of Medicine–Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (L.T.); (J.V.); (K.S.); (J.P.); (J.H.-H.)
| | - Joshua Perez
- College of Medicine–Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (L.T.); (J.V.); (K.S.); (J.P.); (J.H.-H.)
| | - Justin Zeien
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Danyi Li
- Keck School of Medicine Preventive Medicine, University of Southern California, Los Angeles, CA 90032, USA;
| | - Jennifer Hartmark-Hill
- College of Medicine–Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (L.T.); (J.V.); (K.S.); (J.P.); (J.H.-H.)
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5
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Subramanian K, Alayo QA, Sedarous M, Nwaiwu O, Okafor PN. Healthcare Disparities Among Homeless Patients Hospitalized With Gastrointestinal Bleeding: A Propensity-Matched, State-Level Analysis. J Clin Gastroenterol 2023; 57:707-713. [PMID: 36730876 DOI: 10.1097/mcg.0000000000001742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
GOALS Examine outcomes among homeless patients admitted with gastrointestinal (GI) bleeding, including all-cause mortality and endoscopic intervention rates. BACKGROUND Hospitalizations among homeless individuals have increased steadily since at least 2007 but little is known about GI outcomes in these patients. STUDY The 2010-2014 Healthcare Utilization Project (HCUP) State Inpatient Databases from New York and Florida were used to identify adults admitted with a primary diagnosis of acute upper or lower GI bleed. Homeless patients were 1:3 matched with nonhomeless patients using a propensity-score greedy-matched algorithm. The primary outcome (all-cause in-hospital mortality) and secondary outcomes (30-day readmission rates, endoscopy utilization, length of stay, and total hospitalization costs) were compared. RESULTS We matched 4074 homeless patients with 12,222 nonhomeless patients. Most hospitalizations for homeless individuals were concentrated in 113 (26.4%) of 428 hospitals. Homeless adults were more likely to be younger, male, African American or Hispanic, and on Medicaid. They experienced significantly higher odds of all-cause inpatient mortality compared with nonhomeless patients admitted with GI bleeding (OR 1.37, 95% CI 1.11-1.69). Endoscopy utilization rates were also lower for both upper (OR 0.62, 95% CI 0.55-0.71) and lower (OR 0.76, 95% CI 0.68-0.85) GI bleeding, though upper endoscopy rates within the first 24 hours were comparable (OR 1.11, 95% CI 1.00-1.23). Total hospitalization costs were lower ($9,715 vs. $12,173, P <0.001) while 30-day all-cause readmission rates were significantly higher in the homeless group (14.9% vs. 18.4%, P <0.001). CONCLUSIONS Homeless patients hospitalized for GI bleeding face disparities, including higher mortality rates and lower endoscopy utilization.
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Affiliation(s)
- Kavitha Subramanian
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Quazim A Alayo
- Division of Internal Medicine, St. Luke's Hospital, Chesterfield, MO, USA
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, MO
| | - Mary Sedarous
- Department of Medicine, McMaster University, Hamilton, ON L8S4L8
| | - Obioma Nwaiwu
- Department of Medicine, University of Arkansas School of Medical Sciences, Little Rock, AR
| | - Philip N Okafor
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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The Impact of COVID-19 on Access to Resources among Individuals Experiencing Homelessness and Traumatic Brain Injury. TRAUMA CARE 2023. [DOI: 10.3390/traumacare3010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
The rates of traumatic brain injury (TBI) are higher among individuals experiencing homelessness compared with the general population. Individuals experiencing homelessness and a TBI may experience barriers to care. COVID-19 may have further impacted access to basic resources, such as food, shelter, and transportation for individuals experiencing homelessness. This study aimed to answer the following research question: What is the impact of COVID-19 on access to resources among individuals experiencing homelessness and TBI? A cross-sectional study design and purposive sampling were utilized to interview 38 English-speaking adults experiencing homelessness and who had sustained a TBI (ages 21–73) in one Colorado city. Qualitative questions related to the impact of COVID-19 were asked and qualitative analysis was used to analyze the responses. Three primary themes emerged regarding the types of resources that were restricted by COVID-19: basic/biological needs, financial needs, and a lack of connection. COVID-19 has shown the social work field the need for continued innovation and better practice standards for individuals who are not housed. For those living with a reported TBI history and experiencing homelessness, COVID-19 made it difficult to access basic services for survival.
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Mayo ZS, Campbell SR, Shah CS, Weleff J, Kilic SS. Improving Treatment Interventions and Cancer Outcomes in Persons Experiencing Homelessness: A Population Underrepresented in Equity Initiatives. Int J Radiat Oncol Biol Phys 2023; 115:302-304. [PMID: 36621233 DOI: 10.1016/j.ijrobp.2022.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH.
| | | | - Chirag S Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH; Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Sarah S Kilic
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
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Aydin-Ghormoz H, Adeyeye T, Muscatiello N, Nayak S, Savadatti S, Insaf TZ. Identifying Risk Factors for Hospitalization with Behavioral Health Disorders and Concurrent Temperature-Related Illness in New York State. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16411. [PMID: 36554292 PMCID: PMC9779268 DOI: 10.3390/ijerph192416411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
Extreme temperature events are linked to increased emergency department visits, hospitalizations, and mortality for individuals with behavioral health disorders (BHD). This study aims to characterize risk factors for concurrent temperature-related illness among BHD hospitalizations in New York State. Using data from the NYS Statewide and Planning Research and Cooperative System between 2005-2019, multivariate log binomial regression models were used in a population of BHD hospitalizations to estimate risk ratios (RR) for a concurrent heat-related (HRI) or cold-related illness (CRI). Dementia (RR 1.65; 95% CI:1.49, 1.83) and schizophrenia (RR 1.38; 95% CI:1.19, 1.60) were associated with an increased risk for HRI among BHD hospitalizations, while alcohol dependence (RR 2.10; 95% CI:1.99, 2.22), dementia (RR 1.52; 95% CI:1.44, 1.60), schizophrenia (RR 1.41; 95% CI:1.31, 1.52), and non-dependent drug/alcohol use (RR 1.20; 95% CI:1.15, 1.26) were associated with an increased risk of CRI among BHD hospitalizations. Risk factors for concurrent HRI among BHD hospitalizations include increasing age, male gender, non-Hispanic Black race, and medium hospital size. Risk factors for concurrent CRI among BHD hospitalizations include increasing age, male gender, non-Hispanic Black race, insurance payor, the presence of respiratory disease, and rural hospital location. This study adds to the literature by identifying dementia, schizophrenia, substance-use disorders, including alcohol dependence and non-dependent substance-use, and other sociodemographic factors as risk factors for a concurrent CRI in BHD hospitalizations.
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Affiliation(s)
- Heather Aydin-Ghormoz
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
- School of Public Health, University at Albany, Rensselaer, NY 12144, USA
| | - Temilayo Adeyeye
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
- School of Public Health, University at Albany, Rensselaer, NY 12144, USA
| | - Neil Muscatiello
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
| | - Seema Nayak
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
| | - Sanghamitra Savadatti
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
- School of Public Health, University at Albany, Rensselaer, NY 12144, USA
| | - Tabassum Z. Insaf
- Center for Environmental Health, New York State Department of Health, Albany, NY 12208, USA
- School of Public Health, University at Albany, Rensselaer, NY 12144, USA
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Ng Kamstra JS, Molina T, Halliday T. Compact for care: how the Affordable Care Act marketplaces fell short for a vulnerable population in Hawaii. BMJ Glob Health 2021; 6:bmjgh-2021-007701. [PMID: 34845000 PMCID: PMC8634008 DOI: 10.1136/bmjgh-2021-007701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/08/2021] [Indexed: 11/12/2022] Open
Abstract
The Patient Protection and Affordable Care Act (ACA) was passed in 2010 to expand access to health insurance in the USA and promote innovation in health care delivery. While the law significantly reduced the proportion of uninsured, the market-based protection it provides for poor and vulnerable US residents is an imperfect substitute for government programs such as Medicaid. In 2015, residents of Hawaii from three Compact of Free Association nations (the Federated States of Micronesia, Palau and Marshall Islands) lost their eligibility for the state’s Medicaid program and were instructed to enrol in coverage via the ACA marketplace. This transition resulted in worsened access to health care and ultimately increased mortality in this group. We explain these changes via four mechanisms: difficulty communicating the policy change to affected individuals, administrative barriers to coverage under the ACA, increased out of pocket health care costs and short enrolment windows. To achieve universal health coverage in the USA, these challenges must be addressed by policy-makers.
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Affiliation(s)
- Joshua S Ng Kamstra
- The Queen's Health Systems, Honolulu, Hawaii, USA .,Department of Surgery, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Teresa Molina
- Department of Economics, University of Hawai'i at Manoa, Honolulu, Hawaii, USA.,IZA Institute of Labor Economics, Bonn, Nordrhein-Westfalen, Germany
| | - Timothy Halliday
- Department of Economics, University of Hawai'i at Manoa, Honolulu, Hawaii, USA.,IZA Institute of Labor Economics, Bonn, Nordrhein-Westfalen, Germany
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Pidgeon H, McKinney D, Tan-Creevy J, Shah M, Ansari S, Gottlieb M. Thinking Beyond the Emergency Department: Addressing Homelessness in Residency Education. Ann Emerg Med 2021; 79:397-403. [PMID: 34607743 DOI: 10.1016/j.annemergmed.2021.07.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Harrison Pidgeon
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Dennis McKinney
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Jeny Tan-Creevy
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Meeta Shah
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Sobia Ansari
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Montgomery MP, Carry MG, Garcia‐Williams AG, Marshall B, Besrat B, Bejarano F, Carlson J, Rutledge T, Mosites E. Hand hygiene during the COVID-19 pandemic among people experiencing homelessness-Atlanta, Georgia, 2020. JOURNAL OF COMMUNITY PSYCHOLOGY 2021; 49:2441-2453. [PMID: 33899228 PMCID: PMC8242516 DOI: 10.1002/jcop.22583] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 05/27/2023]
Abstract
People experiencing homelessness are at risk for coronavirus disease 2019 (COVID-19) and may experience barriers to hand hygiene, a primary recommendation for COVID-19 prevention. We conducted in-depth interviews with 51 people experiencing sheltered and unsheltered homelessness in Atlanta, Georgia during May 2020 to August 2020 to (1) describe challenges and opportunities related to hand hygiene and (2) assess hand hygiene communication preferences. The primary hand hygiene barrier reported was limited access to facilities and supplies, which has disproportionately impacted people experiencing unsheltered homelessness. This lack of access has reportedly been exacerbated during COVID-19 by the closure of public facilities and businesses. Increased access to housing and employment were identified as long-term solutions to improving hand hygiene. Overall, participants expressed a preference for access to facilities and supplies over hand hygiene communication materials.
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Affiliation(s)
- Martha P. Montgomery
- COVID‐19 Emergency Response, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Monique G. Carry
- COVID‐19 Emergency Response, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | - Brittany Marshall
- COVID‐19 Emergency Response, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Bethlehem Besrat
- COVID‐19 Emergency Response, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | | | - Ty Rutledge
- Intown Collaborative MinistriesAtlantaGeorgiaUSA
| | - Emily Mosites
- COVID‐19 Emergency Response, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
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12
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Wang R, Guth A, Tate A, Ly M, Plumb J. Filling Gaps and Setting Boundaries: Examining Utilization of Health and Social services at JeffHOPE Student Run Clinics. J Prim Care Community Health 2021; 12:21501327211037532. [PMID: 34369185 PMCID: PMC8358486 DOI: 10.1177/21501327211037532] [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] [Indexed: 11/17/2022] Open
Abstract
The objective of this study was to describe the frequency that healthcare and social support services offered by JeffHOPE, a student run clinic for people experiencing homelessness in Philadelphia, PA, were utilized by patients. This study also aimed to investigate where patients would seek medical care on a given day had they not been able to access JeffHOPE. This study was conducted via mixed methods consisting of retrospective chart review of patient encounter records and a patient survey conducted weekly throughout 2019, both at a single clinic site, and retrospective chart review of January through March 2020 records at 5 clinic sites. This study found that the frequency of services utilized varied between clinic sites, and that Pharmacy and Procedure committees were the most utilized when examining the combined clinic data. Additionally, the survey found that JeffHOPE provided medical care to those that otherwise would not have sought it. Clinics also served as an alternative to accessing care for non-emergent issues in an Emergency Department (ED) for some patients, but for others it replaced seeing their primary care provider (PCP). This study confirmed that the services offered by JeffHOPE are well-utilized by patients experiencing homelessness in Philadelphia. It also revealed that while the organization's medical services filled care gaps and potentially decreased unnecessary ED visits, they were also sometimes accessed in lieu of a PCP visit. A focused effort on linkage to formal primary care services for all JeffHOPE patients and expanding collection of more granular data to all clinics represent important future endeavors for this student run organization.
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Affiliation(s)
- Roy Wang
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Amanda Guth
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Alyssa Tate
- Thomas Jefferson University, Philadelphia, PA, USA.,University of Nevada, Reno, Reno, NV, USA
| | - Michele Ly
- Thomas Jefferson University, Philadelphia, PA, USA
| | - James Plumb
- Thomas Jefferson University, Philadelphia, PA, USA
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13
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Kennedy AJ, Bakalov V, Reyes-Uribe L, Kensler C, Connor SE, Benson M, Bui T, Radomski TR. Free Clinic Patients' Perceptions and Barriers to Applying for Health Insurance After Implementation of the Affordable Care Act. J Community Health 2021; 45:492-500. [PMID: 31673862 DOI: 10.1007/s10900-019-00766-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite implementation of the Affordable Care Act (ACA), many Americans remain uninsured and receive care in free clinics. It is unknown what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. The objective of this study was to assess the perceptions and experiences of free clinic patients from southwestern Pennsylvania when applying for health insurance after implementation of the ACA. We designed and implemented a survey of patients at three free clinics within Allegheny County, Pennsylvania from September 2016 to February 2017. Our survey included 22-items, 7 sociodemographic questions and 15 questions regarding the patient's health status and their perspectives related to obtaining health insurance. Data was obtained from 203 patient surveys; 110 (55.3%) of the respondents were men and 99 (48.8%) were African American. There were 48 respondents (24.1%) who did not report any income at the time of the study, and of those that did report an income, 92 (46.2%) respondents reported an income below 133% of the federal poverty level. The main barriers patients faced when applying for health insurance were: (1) lack of knowledge about health insurance (n = 127, 58.1%), (2) cost of health coverage (n = 85, 41.9%), (3) lack of resources (n = 83, 40.4%), and (4) lack of enrollment documentation (n = 43, 23.8%). Significant work is needed to better educate patients about their eligibility and options for health insurance. Free clinics can play a key role in eliminating barriers to health insurance enrollment.
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Affiliation(s)
- Amy J Kennedy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
| | - Veli Bakalov
- Department of Internal Medicine, Allegheny Heath Network, Pittsburgh, PA, 15212, USA
| | - Laura Reyes-Uribe
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Caroline Kensler
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Sharon E Connor
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15261, USA
| | - Maggie Benson
- Division of General Internal Medicine, UPMC Hamot, Erie, PA, 16550, USA
| | - Thuy Bui
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Thomas R Radomski
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, 15213, USA
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14
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A Survey on HIV, HCV, and HBV and Related Factors Among the Homeless Population, Southeast of Iran. HEALTH SCOPE 2021. [DOI: 10.5812/jhealthscope.108929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Homeless people are prone to sexually transmitted and blood-borne infectious diseases such as hepatitis B, hepatitis C, and HIV due to their risky behaviors and low awareness of various diseases. Objectives: Thus, the present research aimed to examine the epidemiologic patterns of HBV, HCV, HIV, and related factors among the homeless population of Zahedan in 2019. Methods: A cross-sectional study was conducted on a total of 329 homeless people. Eligible people were selected using a convenience sampling method from homeless individuals residing in care centers affiliated with the Welfare Organization and the Health Deputy of Zahedan University of Medical Sciences. Data on the demographic and behavioral characteristics of the cases were collected through a structured questionnaire completed in face-to-face interviews. A 10 cc blood sample was taken from each of the cases for serological tests of hepatitis B, hepatitis C, and HIV. The test results and collected data were entered in SPSS16 software. Logistic regression analysis and chi-square tests were used to analyze the data. Results: The majority of the cases (84%) were males, and 59% were in the age-group of 35 - 50 years. Of the subjects, 93% had a history of drug abuse, 74% reported a history of smoking, and 45% had tattoos. The prevalence of hepatitis C, hepatitis B, and HIV was 13%, 2.7%, and 0.3%, respectively (only one case of HIV was identified). In a multi-variate model, imprisonment history [OR = 2.32 (1.08 - 4.98)], history of sexual abuse [OR = 3.73 (1.36 - 10.26)], being widowed or divorced [OR = 2.83, (1.21 - 6.64)], and history of injection with shared needles and syringes [OR = 5.11 (1.97 - 13.28)] remained the predicting factors of hepatitis C. Conclusions: Based on the obtained results of the study, homeless people are more prone to infections with HCV, HBV, and HIV due to their risky behaviors. Therefore, a need is highlighted for preventive interventions and developing the level of health literacy in this group regarding behaviors contributing to the aforementioned infections.
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15
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Goldstein EV. Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211022618. [PMID: 34088240 PMCID: PMC8182175 DOI: 10.1177/00469580211022618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 12/05/2022]
Abstract
The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) providing primary care in medically-underserved communities. However, beyond evidence of initial policy effects, little is understood in the scholarly literature about whether the ACA Medicaid expansion affected longer-lasting changes in CHC patient insurance mix. This study's objective was to examine whether the ACA Medicaid expansion was associated with lasting increases in the annual percentage of adult CHC patients covered by Medicaid and decreases in the annual percentage of uninsured adult CHC patients at expansion-state CHCs, compared to non-expansion-state CHCs. This observational study examined 5353 CHC-year observations from 2012 to 2018 using Uniform Data System data and other national data sources. Using a 2-way fixed-effects multivariable regression approach and marginal analysis, intermediate-term policy effects of the Medicaid expansion on annual CHC patient coverage outcomes were estimated. By 5-years post-expansion, the Medicaid expansion was associated with an overall average increase of 11.7 percentage points in the percentage of adult patients with Medicaid coverage at expansion-state CHCs, compared to non-expansion-state CHCs. Among expansion-state CHCs, 39.8% of adult patients were predicted to have Medicaid coverage 5-years post-expansion, compared to 19.0% of non-expansion-state adult CHC patients. A state's decision to expand Medicaid was similarly associated with decreases in the annual percentage of uninsured adult CHC patients. Primary care operations at CHCs critically depend on patient Medicaid revenue. These findings suggest the ACA Medicaid expansion may provide longer-term financial security for expansion-state CHCs, which maintain increases in Medicaid-covered adult patients even 5-years post-expansion. However, these financial securities may be jeopardized should the ACA be ruled unconstitutional in 2021, a year after CHCs experienced new uncertainties caused by COVID-19.
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16
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Yoon JC, Montgomery MP, Buff AM, Boyd AT, Jamison C, Hernandez A, Schmit K, Shah S, Ajoku S, Holland DP, Prieto J, Smith S, Swancutt MA, Turner K, Andrews T, Flowers K, Wells A, Marchman C, Laney E, Bixler D, Cavanaugh S, Flowers N, Gaffga N, Ko JY, Paulin HN, Weng MK, Mosites E, Morris SB. COVID-19 Prevalence among People Experiencing Homelessness and Homelessness Service Staff during Early Community Transmission in Atlanta, Georgia, April-May 2020. Clin Infect Dis 2020; 73:e2978-e2984. [PMID: 32898272 PMCID: PMC7499502 DOI: 10.1093/cid/ciaa1340] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/02/2020] [Indexed: 11/28/2022] Open
Abstract
Background In response to reported COVID-19 outbreaks among people experiencing homelessness (PEH) in other U.S. cities, we conducted multiple, proactive, facility-wide testing events for PEH living sheltered and unsheltered and homelessness service staff in Atlanta, Georgia. We describe SARS-CoV-2 prevalence and associated symptoms and review shelter infection prevention and control (IPC) policies Methods PEH and staff were tested for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) during April 7–May 6, 2020. A subset of PEH and staff was screened for symptoms. Shelter assessments were conducted concurrently at a convenience sample of shelters using a standardized questionnaire Results Overall, 2,875 individuals at 24 shelters and nine unsheltered outreach events underwent SARS-CoV-2 testing and 2,860 (99.5%) had conclusive test results. SARS-CoV-2 prevalence was 2.1% (36/1,684) among PEH living sheltered, 0.5% (3/628) among PEH living unsheltered, and 1.3% (7/548) among staff. Reporting fever, cough, or shortness of breath in the last week during symptom screening was 14% sensitive and 89% specific for identifying COVID-19 cases compared with RT-PCR. Prevalence by shelter ranged 0%–27.6%. Repeat testing 3–4 weeks later at four shelters documented decreased SARS-CoV-2 prevalence (0%–3.9%). Nine of 24 shelters completed shelter assessments and implemented IPC measures as part of the COVID-19 response Conclusions PEH living in shelters experienced higher SARS-CoV-2 prevalence compared with PEH living unsheltered. Facility-wide testing in congregate settings allowed for identification and isolation of COVID-19 cases and is an important strategy to interrupt SARS-CoV-2 transmission
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Affiliation(s)
- Jane C Yoon
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha P Montgomery
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ann M Buff
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrew T Boyd
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Calla Jamison
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfonso Hernandez
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristine Schmit
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarita Shah
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - David P Holland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Fulton County Board of Health, Atlanta, GA, USA
| | | | - Sasha Smith
- Fulton County Board of Health, Atlanta, GA, USA
| | | | - Kim Turner
- Fulton County Board of Health, Atlanta, GA, USA
| | | | | | | | | | - Emaline Laney
- Emory University School of Medicine, Atlanta, GA, USA
| | - Danae Bixler
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sean Cavanaugh
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nicole Flowers
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nicholas Gaffga
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jean Y Ko
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Heather N Paulin
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark K Weng
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emily Mosites
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sapna Bamrah Morris
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
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17
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Differences in Utilization of Medical and Dental Services among Homeless People in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155304. [PMID: 32717950 PMCID: PMC7432539 DOI: 10.3390/ijerph17155304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
(1) Background: Homelessness contributes to both needs for care and barriers to access. This study aimed to explore the utilization of medical or dental services using Andersen's model for a vulnerable population of homeless in South Korea. (2) Methods: The data were applied from the first national survey for homeless people in South Korea, 2016. Totally 2032 persons participated in the interview survey. This study team requested the raw data through the public portal and analyzed them. (3) Results: The participants who were homeless for more than ten years, staying in small rooming house or shelter, non-employed, earning less than 500,000 won per month, and having a medical condition showed a significantly higher chance of using Medicaid. The use of outreach programs had a significant relationship with gender, duration of homelessness, and monthly income. Among dental patients, the homeless who did not consume alcohol, stayed in a shelter, and were employed had higher chances of using dental service. (4) Conclusions: Medicaid service was strongly related to enabling factors but outreach programs with predisposing factors. Dental service showed strong relationships with the enabling domain, but the pattern was opposite: the jobless had less chance to avail it. The policymakers need to consider these domains of service utilization to provide equitable access to healthcare services.
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18
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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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19
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Jackson TS, Moran TP, Lin J, Ackerman J, Salhi BA. Homelessness Among Patients in a Southeastern Safety Net Emergency Department. South Med J 2019; 112:476-482. [PMID: 31485585 DOI: 10.14423/smj.0000000000001016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Emergency departments (EDs) are important providers for homeless individuals, providing vital health care and meeting the subsistence needs of many homeless patients (eg, food, water, shelter). Studies that have examined the proportion of patients in the ED setting who experience homelessness have been conducted primarily in the northeastern United States. We hypothesized that findings from prior studies, conducted primarily in the Northeast, would not generalize to other regions of the United States. We conducted a direct patient survey to describe the proportion and demographics of ED patients who have experienced homelessness within the past 12 months in an urban safety net hospital in Atlanta, Georgia. METHODS A cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016. A team of trained research assistants administered a structured survey instrument to patients who were 18 years old, English speakers, not incarcerated, and able to provide informed consent. Questions were based on the US Department of Health and Human Services definition of homelessness. RESULTS A total of 923 ED patients (55.1% male; median age 44 years) completed the survey. Of the ED patients surveyed, 51.5% reported some measure of homelessness in the past 12 months: lived with others but did not pay rent (n = 279, 30.2%), skipped mortgage or rent payment (n = 111, 12%), experienced eviction (n = 74, 8%), lived in a hotel or motel (n = 196, 21.2%), lived in a place not meant for human habitation (n = 76, 8.2%), slept in a shelter (n = 131, 14.2%), and slept on the street (n = 115, 12.5%). Men (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.17-2.09), patients who completed some school (OR 2.85, 95% CI 1.72-4.71), and patients who completed high school (OR 2.32, 95% CI 1.53-3.52) were more likely to have experienced homelessness in the 12 months preceding their ED visit. CONCLUSIONS The rate of patients experiencing homelessness at our hospital is substantially greater than those reported in prior surveys of ED patients. More research is needed on homelessness and its implications for ED patients.
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Affiliation(s)
- Toni S Jackson
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Tim P Moran
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Jonathan Lin
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Jeremy Ackerman
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Bisan A Salhi
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
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20
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Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing, Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release. J Urban Health 2018; 95:454-466. [PMID: 29934825 PMCID: PMC6095764 DOI: 10.1007/s11524-018-0275-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates' financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants' Medicaid enrollment prior to prison and intentions to enroll after release. Study participants' median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran's Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid-and other social safety net programs-may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.
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21
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Salhi BA, White MH, Pitts SR, Wright DW. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med 2018; 25:577-593. [PMID: 29223132 DOI: 10.1111/acem.13358] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/24/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research. METHODS We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature. RESULTS Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients. CONCLUSION Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.
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Affiliation(s)
- Bisan A. Salhi
- Department of Emergency Medicine Emory University Atlanta GA
- Department of Anthropology Emory University Atlanta GA
| | | | | | - David W. Wright
- Department of Emergency Medicine Emory University Atlanta GA
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22
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Insurance Enrollment at a Student-Run Free Clinic After the Patient Protection and Affordable Care Act. J Community Health 2018; 42:785-790. [PMID: 28260143 DOI: 10.1007/s10900-017-0318-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA) aims to increase insurance coverage through government subsidies. Medical student-run free clinics (SRFC) are an important entry point into the healthcare system for the uninsured. SRFCs do not have a standardized approach for navigating the complexities of enrollment. The Weill Cornell Community Clinic (WCCC) developed a unique enrollment model that may inform other SRFCs. Our objective is to describe enrollment processes at SRFCs throughout New York City, and to evaluate enrollment outcomes and persistent barriers to coverage at WCCC. We surveyed SRFC leadership throughout NYC to understand enrollment processes. We evaluated enrollment outcomes at WCCC through chart review and structured phone interviews. Subjects included WCCC patients seen in clinic between October 1, 2013 and September 30, 2015 (N = 140). Demographic information, method of insurance enrollment, and qualitative description of enrollment barriers were collected. SRFCs in New York City have diverse enrollment processes. 48% (N = 42) of WCCC patients obtained health insurance. Immigration status was a barrier to coverage in 21% of patients. Failure to gain coverage was predicted by larger household size (p = 0.02). Gender and employment status were not associated with remaining uninsured. The main barriers to enrollment were inability to afford premiums and lack of interest. Insurance enrollment processes at SRFCs in New York City are mostly ad hoc and outcomes are rarely tracked. Following implementation of the ACA, WCCC stands out for its structured approach, with approximately half of eligible WCCC patients gaining coverage during the study period.
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23
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Malecha PW, Williams JH, Kunzler NM, Goldfrank LR, Alter HJ, Doran KM. Material Needs of Emergency Department Patients: A Systematic Review. Acad Emerg Med 2018; 25:330-359. [PMID: 29266523 DOI: 10.1111/acem.13370] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States. METHODS We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles. RESULTS Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs. CONCLUSIONS Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.
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Affiliation(s)
| | - James H. Williams
- Department of Emergency Medicine Harbor–UCLA Medical Center TorranceCA
| | - Nathan M. Kunzler
- Brigham and Women's/Massachusetts General Hospital Harvard Affiliated Emergency Medicine Boston MA
| | - Lewis R. Goldfrank
- Ronald O. Perelman Department of Emergency Medicine NYU School of Medicine New York NY
| | - Harrison J. Alter
- Department of Emergency Medicine Highland Hospital–Alameda Health System Oakland CA
| | - Kelly M. Doran
- Ronald O. Perelman Department of Emergency Medicine NYU School of Medicine New York NY
- Department of Population Health NYU School of Medicine New York NY
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24
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Gable AR, Der-Martirosian C, Dobalian A. Access to Care for Homeless Veterans During Disasters. J Prim Care Community Health 2018. [PMCID: PMC6287296 DOI: 10.1177/2150132718815382] [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] [Indexed: 11/27/2022] Open
Abstract
Introduction: Since 1970, natural disasters have led to both temporary and permanent closures of multiple medical centers and outpatient clinics at the US Department of Veterans Affairs (VA) nationwide. Access to care during such events is critical for vulnerable populations, especially homeless veterans. As such, facility closures may disproportionately affect homeless veteran patients who are both more likely to experience adverse effects from disasters and face multiple barriers to care. Methods: A cross-sectional survey was administered to a probability sample of 2000 homeless VA patients living in and receiving VA health care in the Northeast United States. The survey was completed by 383 respondents (20% adjusted response rate). This pilot study examines predictors of difficulty accessing care in the event that the VA facility that homeless VA patients routinely use is forced to close because of a natural disaster. Results: In a multivariate logistic regression, homeless VA patients who had Medicaid were less likely (OR 0.38; 95% CI: 0.18-0.78; P < .01) to report that they would have difficulty obtaining care elsewhere if their normal VA facility was closed in a future natural disaster. Conclusions: Findings suggest that Medicaid coverage has the potential to facilitate access to care for homeless veteran VA patients during disasters. Policy changes that decrease Medicaid coverage could limit access to care for homeless veterans during closures of VA medical facilities.
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Affiliation(s)
- Alicia R. Gable
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, North Hills, CA, USA
| | - Claudia Der-Martirosian
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, North Hills, CA, USA
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, North Hills, CA, USA
- University of Memphis School of Public Health, Memphis, TN, USA
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Expanded Medicaid Provides Access to Substance Use, Mental Health, and Physician Visits to Homeless and Precariously Housed Persons. J Community Health 2017; 43:207-211. [DOI: 10.1007/s10900-017-0405-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Raven MC, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study. Acad Emerg Med 2017; 24:63-74. [PMID: 27520382 DOI: 10.1111/acem.13070] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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Affiliation(s)
- Maria C. Raven
- Department of Emergency Medicine University of California at San Francisco San Francisco CA
- Philip R. Lee Institute for Health Policy Studies University of California at San Francisco San Francisco CA
| | - Lina Tieu
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Christopher T. Lee
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Claudia Ponath
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - David Guzman
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Margot Kushel
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
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