Caring for Homeless Persons with Serious Mental Illness in General Hospitals

Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal

BACKGROUND

Our goal was to identify the demographic profile of the people living homeless with mental illness in Lisboa, Portugal, and their relationship with the national healthcare system. We also tried to understand which factors contribute to the number and duration of psychiatric admissions among these homeless people.

METHODS

We used a cross-sectional design, collecting data for 4 years among homeless people, in Lisboa, Portugal, that were referred as possible psychiatric patients to Centro Hospitalar Psiquiátrico de Lisboa (CHPL). In total, we collected data from 500 homeless people, then cross-checked these people in our CHPL hospital electronic database and obtained 467 patient matches.

RESULTS

The most common psychiatric diagnosis in our sample was drug abuse (34%), followed by alcohol abuse (33%), personality disorder (24%), and acute stress reaction (23%). Sixty-two percent of our patients had multiple diagnoses, a subgroup with longer follow-ups, more psychiatric hospitalizations, and longer psychiatric hospitalizations. The prevalence of psychotic disorders was high: organic psychosis (17%), schizophrenia (15%), psychosis not otherwise specified (14%), and schizoaffective disorder (11%), that combined altogether were present in more than half (57%) of our homeless patients.

CONCLUSION

The people living homeless with multiple diagnoses have higher mental health needs and worse determinants of general health. An ongoing effort is needed to identify and address this subgroup of homeless people with mental illness to improve their treatment and outcomes.

The Impact of an Educational Intervention on Nursing Staff Attitudes Toward Patients Experiencing Homelessness and Mental Illness

OBJECTIVE

Patients who experience homelessness and have mental illness can have frequent and challenging hospitalizations. Nurses caring for this vulnerable population may have negative attitudes, which can be mitigated by education and improved for the benefit of patients. This study aimed to assess the impact of an educational intervention on the attitudes of nursing staff toward individuals experiencing homelessness and mental illness.

METHODS

Using a pre-post design, a revised version of the Health Professionals' Attitudes Toward the Homeless Inventory (HPATHI) assessed 23 nursing staff working on inpatient medicine units surrounding a brief educational session about persons experiencing homelessness and mental illness. Data were also collected from open-ended questions.

RESULTS

There was a small positive increase in mean HPATHI scores postintervention (74.783 [SD = 5.485] to 77.13 [SD = 6.312]) indicating more positive participant attitudes toward homeless individuals. The HPATHI also revealed a 6% increase in score for participant comfortability providing care for homeless persons with major mental illness postintervention. Some participants likely interpreted their answers as displaying more positive and less cynical attitudes based on their comments, while the HPATHI scored them as more negative. Qualitative feedback revealed both positive and negative attitudes toward this patient population, and various associated barriers to care.

CONCLUSIONS

Nursing staff will likely provide care for patients who experience homelessness with concomitant mental illness. Educating nurses about the needs of this population is feasible and could be beneficial for patient care.

Comorbidity profiles of patients experiencing homelessness: A latent class analysis

Individuals experiencing homelessness are known to have increased rates of healthcare utilization when compared to the average patient population, often attributed to their complex health care needs and under or untreated comorbid conditions. With increasing focus on hospital readmissions among acute care settings, a better understanding of these comorbidity patterns and their impacts on acute care utilization could help improve quality of care. This study aims to identify distinct comorbidity profiles of homeless patients, and to explore the correlates of the identified comorbidity profiles and their impact on hospital readmission. This is a retrospective analysis using electronic health records (EHR) of patients experiencing homelessness encountered in the hospitals of ChristianaCare from 2015 to 2019 (N = 3445). Latent class analysis (LCA) was used to identify the comorbidity profiles of homeless patients. The mean age of the study population was 44-year, and the majority were male (63%). The most prevalent comorbid conditions were tobacco use (77%), followed by depression (58%), drug use disorder (56%), anxiety disorder (50%), hypertension (44%), and alcohol use disorder (43%). The LCA model identified 4 comorbidity classes-"relatively healthy" class with 31% of the patients, "medically-comorbid with SUD" class with 15% of the patients, "substance use disorder (SUD)" class with 39%, and "Medically comorbid" class with 15% of the patients. The Kaplan-Meir curves of probability of readmission against time from the index visits were significantly different for the four classes (p<0.001). The multivariable Cox proportional hazard model adjusted for age, sex, race, ethnicity, and insurance type showed that the hazard for readmission among patients in medically comorbid with SUD class is 3.16 (CI: 2.72, 3.67) times higher than the patients in the relatively healthy class.

Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey

Objectives:

Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences.

Methods:

We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs.

Results:

Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7).

Conclusions:

Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot

INTRODUCTION

Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area.

AIMS AND METHODS

We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up.

RESULTS

At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up.

CONCLUSIONS

In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents.

IMPLICATIONS

To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.

Impact on the use and cost of other services following intervention by an inpatient pathway homelessness team in an acute mental health hospital

Background: Mental illness in people experiencing homelessness is common and a key reason for attendance at emergency departments and admission to hospital.Aims: This paper describes how the KHP Pathway homeless team impacted use and cost of health and wider services. The Pathway model had never been adopted by a mental health hospital, and there had never been an economic analysis to evaluate service use before and after intervention.Method: Service use was measured using an adapted version of the Client Service Receipt Inventory (CSRI) with a simple before and after design at admission, 3 months and 6 months after discharge from hospital.Results: During the first 3-month follow-up, over half the participants saw a GP, with an increase in the proportion seeing a psychiatrist, social worker and a mental health nurse. Attendance at emergency departments was substantially lower than at baseline. The mean total service cost was £818 at base line and £414 at 3 months.Conclusions: The adapted version of the CSRI demonstrates that patients seen by the Pathway Homelessness Team were supported to use community and scheduled health and care services. The service overcomes barriers, frequently experienced by people experiencing homelessness, in accessing support and community healthcare in the UK.

Violence and Emergency Department Use among Community-Recruited Women Who Experience Homelessness and Housing Instability

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (ORphysical/weapon = 1.83, 95% CI 1.02-3.28; ORsexual = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.

Deaths among homeless in northern Tunisia: a 10-year study (2005-2014)

OBJECTIVE

To analyze the victims profile related to death among homeless people.

STUDY DESIGN

A descriptive, retrospective, and cross-sectional study.

METHODS

We included all deaths among homeless people that occurred during a 10-year period (2005-2014) that were autopsied in the Department of Legal Medicine of the Charles Nicolle Hospital of Tunis. Causes of death were classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision. Data were classified in three sections: sociodemographic data, circumstances of death, and autopsy findings. A univariate data analysis was performed.

RESULTS

The sex ratio (M/F) was of 7.45. The average age was of 59 years. The majority of deaths (80.9%) occurred in the metropolis of Tunis with a significant occurrence of cases in other governorates after the 2011 revolution (P = 0.002). Deaths occurred more often during winter (34.8%). The bodies were frequently discovered in public places (36.0%) and private locations (34.0%). The deaths of 55.3% of cases were attributed to natural causes, significantly affecting the elderly, whereas the accidental causes (25.7%) were more frequent before the age of 49 years, followed by suicides (3.9%) and homicides (3.3%).

CONCLUSIONS

Our study highlighted a phenomenon not yet studied in Tunisia. Our results highlight an urgent need for preventive measures focused on the improvement of healthcare measures among homeless people.

Effect of Housing First on Suicidal Behaviour: A Randomised Controlled Trial of Homeless Adults with Mental Disorders

OBJECTIVE

This study attempted to determine if Housing First (HF) decreased suicidal ideation and attempts compared to treatment as usual (TAU) amongst homeless persons with mental disorders, a population with a demonstrably high risk of suicidal behaviour.

METHOD

The At Home/Chez Soi project is an unblinded, randomised control trial conducted across 5 Canadian cities (Vancouver, Winnipeg, Toronto, Montreal, Moncton) from 2009 to 2013. Homeless adults with a diagnosed major mental health disorder were recruited through community agencies and randomised to HF ( n = 1265) and TAU ( n = 990). HF participants were provided with private housing units and received case management support services. TAU participants retained access to existing community supports. Past-month suicidal ideation was measured at baseline and 6, 12, 18, and 21/24 months. A history of suicide attempts was measured at baseline and the 21/24-month follow-up.

RESULTS

Compared to baseline, there was an overall trend of decreased past-month suicidal ideation (estimate = -.57, SE = .05, P < 0.001), with no effect of treatment group (i.e., HF vs. TAU; estimate = -.04, SE = .06, P = 0.51). Furthermore, there was no effect of treatment status (estimate = -.10, SE = .16, P = 0.52) on prevalence of suicide attempts (HF = 11.9%, TAU = 10.5%) during the 2-year follow-up period.

CONCLUSION

This study failed to find evidence that HF is superior to TAU in reducing suicidal ideation and attempts. We suggest that HF interventions consider supplemental psychological treatments that have proven efficacy in reducing suicidal behaviour. It remains to be determined what kind of suicide prevention interventions (if any) are specifically effective in further reducing suicidal risk in a housing-first intervention.

Ethics and the Treatment of the Mentally Ill, Homeless Person: a Perspective on Psychiatry Resident Training

OBJECTIVE

The authors outline the unique ethical challenges that psychiatry residents face in working with individuals who are homeless and mentally ill. The authors also propose steps to develop effective teaching methods with residents working with these patients.

METHODS

The authors reviewed literature relevant to the training of psychiatry residents in ethics and treating individuals who are homeless and mentally ill.

RESULTS

The authors summarize current literature and, with the use of case examples, provide guidelines for effective teaching.

CONCLUSIONS

Teaching psychiatry residents who are working in the community with individuals who are mentally ill and homeless needs to address a number of unique ethical conflicts that arise in this area. The authors outline approaches to this teaching.

Care of the Homeless Patient

This article discusses the unique considerations when caring for patients who lack housing, one of the most essential human needs. Special attention is provided to diseases and conditions that are affected by homelessness as well as to particularly vulnerable populations of homeless patients.