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Abramson TM, Burner E, Arora S, Wenzel S, Gausche-Hill M. Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors. PREHOSP EMERG CARE 2024:1-8. [PMID: 38771734 DOI: 10.1080/10903127.2024.2358146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis. METHODS We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023). RESULTS Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20). CONCLUSION In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.
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Affiliation(s)
- Tiffany M Abramson
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sanjay Arora
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Suzanne Wenzel
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County EMS Agency, Los Angeles, California
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Biomedical Innovation, Los Angeles, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Choudhury S, Choi SL, Lee Y, Manser SS. Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas. HEALTH & SOCIAL WORK 2024; 49:87-94. [PMID: 38478764 DOI: 10.1093/hsw/hlae002] [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: 05/11/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 04/30/2024]
Abstract
Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.
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Affiliation(s)
- Sumaita Choudhury
- MPH, is a doctoral candidate and research associate, Texas Institute for Excellence in Mental Health, Steve Hicks School of Social Work, University of Texas at Austin, 1823 Red River Street, Austin, TX 78712, USA
| | - Sharon Lee Choi
- PhD, is a research associate, Texas Institute for Excellence in Mental Health, Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA
| | - Yehyang Lee
- MS, is a graduate research assistant, Texas Institute for Excellence in Mental Health, Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA
| | - Stacey Stevens Manser
- PhD, is a research scientist and associate director, Texas Institute for Excellence in Mental Health, Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA
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Harris DR, Anthony N, Quesinberry D, Delcher C. Evidence of housing instability identified by addresses, clinical notes, and diagnostic codes in a real-world population with substance use disorders. J Clin Transl Sci 2023; 7:e196. [PMID: 37771412 PMCID: PMC10523293 DOI: 10.1017/cts.2023.626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Housing instability is a social determinant of health associated with multiple negative health outcomes including substance use disorders (SUDs). Real-world evidence of housing instability is needed to improve translational research on populations with SUDs. Methods We identified evidence of housing instability by leveraging structured diagnosis codes and unstructured clinical data from electronic health records of 20,556 patients from 2017 to 2021. We applied natural language processing with named-entity recognition and pattern matching to unstructured clinical notes with free-text documentation. Additionally, we analyzed semi-structured addresses containing explicit or implicit housing-related labels. We assessed agreement on identification methods by having three experts review of 300 records. Results Diagnostic codes only identified 58.5% of the population identifiable as having housing instability, whereas 41.5% are identifiable from addresses only (7.1%), clinical notes only (30.4%), or both (4.0%). Reviewers unanimously agreed on 79.7% of cases reviewed; a Fleiss' Kappa score of 0.35 suggested fair agreement yet emphasized the difficulty of analyzing patients having ambiguous housing situations. Among those with poisoning episodes related to stimulants or opioids, diagnosis codes were only able to identify 63.9% of those with housing instability. Conclusions All three data sources yield valid evidence of housing instability; each has their own inherent practical use and limitations. Translational researchers requiring comprehensive real-world evidence of housing instability should optimize and implement use of structured and unstructured data. Understanding the role of housing instability and temporary housing facilities is salient in populations with SUDs.
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Affiliation(s)
- Daniel R. Harris
- Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Kentucky, Lexington, KY, USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
| | - Nicholas Anthony
- Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Dana Quesinberry
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Chris Delcher
- Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Cano M, Oh S. State-level homelessness and drug overdose mortality: Evidence from US panel data. Drug Alcohol Depend 2023; 250:110910. [PMID: 37535991 PMCID: PMC10530113 DOI: 10.1016/j.drugalcdep.2023.110910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although homelessness is a well-documented risk factor for drug overdose at the individual level, less is known about state-level homelessness and overdose mortality in the United States (US). METHODS This study used 2007-2020 panel data for all US states and the District of Columbia, from the following sources: US Department of Housing and Urban Development (homelessness data); Centers for Disease Control and Prevention (drug overdose death counts, population estimates, and opioid prescribing rates); Bureau of Labor Statistics (unemployment rates); and the National Forensic Laboratory Information System (drug seizure data). Two-way (state and year) fixed effects models regressed log-transformed drug overdose mortality rates on homelessness prevalence, in nested models adding demographic composition and unemployment measures, as well as drug supply measures. Models were weighted by state population size, and standard errors (SEs) were clustered at the state level. RESULTS Homelessness prevalence was significantly and positively associated with rates of drug overdose mortality after adjusting for nationwide trends, time-invariant differences between states, demographic composition, and unemployment rates (b[SE]=0.98[0.36], p=0.009). The positive association between homelessness prevalence and overdose mortality was attenuated at higher levels of fentanyl availability (fentanyl involvement in drug seizures; interaction term b[SE]=-0.02[0.01], p=0.001). CONCLUSION The positive association between state-level homelessness and drug overdose mortality suggests that policies and programs to prevent and reduce homelessness represent fundamental elements of a comprehensive response to the US overdose crisis.
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Affiliation(s)
| | - Sehun Oh
- The Ohio State University, Columbus, OH, USA
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Curtis TM, Boozarpour O, Rebagliati DE, Colwell CB, Dailey MW. Prehospital Chest Pain Management: Disparity Based on Homeless Status. PREHOSP EMERG CARE 2023; 27:1101-1106. [PMID: 37459650 DOI: 10.1080/10903127.2023.2238309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND People experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain. METHODS We obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician's primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: "chest pain-not cardiac" and "chest-pain-cardiac/STEMI"; ST elevation myocardial infarction (STEMI). RESULTS A total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of "chest pain-not cardiac" compared to "chest pain-cardiac/STEMI" (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: "chest pain-not cardiac" versus "chest pain-cardiac/STEMI." Greater than 97% of all patients received 12 lead electrocardiograms. CONCLUSIONS Significant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.
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Affiliation(s)
| | | | | | - Christopher B Colwell
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - Michael W Dailey
- Department of Emergency Medicine, Albany Medical College, Albany, New York, USA
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Bolster J, Pithia P, Batt AM. Emerging Concepts in the Paramedicine Literature to Inform the Revision of a Pan-Canadian Competency Framework for Paramedics: A Restricted Review. Cureus 2022; 14:e32864. [PMID: 36699791 PMCID: PMC9870303 DOI: 10.7759/cureus.32864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/24/2022] Open
Abstract
The National Occupational Competency Profile (NOCP)-the competency framework for paramedics in Canada-is presently undergoing revision. Since the NOCP was published in 2011, paramedic practice, healthcare, and society have changed dramatically. To inform the revision, we sought to identify emerging concepts in the literature that would inform the development of competencies for paramedics. We conducted a restricted literature review and content analysis of all published and grey literature pertaining to or informing Canadian paramedicine from 2011 to 2022. Three authors performed a title, abstract, and full-text review to identify and label concepts informed by existing findings. A total of 302 articles were categorized into 11 emerging concepts related to competencies: inclusion, diversity, equity, and accessibility (IDEA) in paramedicine; social responsiveness, justice, equity, and access; anti-racism; healthy professionals; evidence-informed practice and systems; complex adaptive systems; learning environment; virtual care; clinical reasoning; adaptive expertise; and planetary health. This review identified emerging concepts to inform the development of the 2023 National Occupational Standard for Paramedics (NOSP). These concepts will inform data analysis, the development of group discussions, and competency identification.
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Affiliation(s)
- Jennifer Bolster
- Paramedicine, Monash University, Melbourne, AUS
- Clinical Governance and Professional Practice, British Columbia Emergency Health Services, Vancouver, CAN
- Centre for Research and Innovation, Fanshawe College, London, CAN
| | - Priya Pithia
- Centre for Research and Innovation, Fanshawe College, London, CAN
| | - Alan M Batt
- Paramedicine, Monash University, Melbourne, AUS
- Centre for Research and Innovation, Fanshawe College, London, CAN
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Nagy-Borsy E, Vági Z, Skerlecz P, Szeitl B, Kiss I, Rákosy Z. Health status and health behaviour of the Hungarian homeless people. ACTA ACUST UNITED AC 2021; 79:15. [PMID: 33531045 PMCID: PMC7852122 DOI: 10.1186/s13690-021-00534-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Homelessness has risen recently in Europe, but there is lack of comprehensive health data on this population. Our aim was to characterize the health of the Hungarian homeless population. METHODS We performed a health survey with 453 homeless individuals. The results were compared to the age and sex standardized data of the general Hungarian population and its lowest income quintile from the European Health Interview Survey 2014. The differences by the ETHOS classification within the homeless population were also studied. RESULTS Significantly fewer homeless people reported good health status than in the general population or in its lowest income quintile (p< 0.001). Of the participants 70% had at least one chronic disease, only 41% of them visited a GP and 35% took medication in the previous 12 months. While 59% of the lowest income quintile and 50% of the general population had at least one chronic disease, almost all of them visited a physician and took medication. The highest prevalence of morbidity (80%) and multimorbidity (46%) was reported in the houseless group. The majority of the homeless people were current smokers, the prevalence was much higher than in the two reference populations (p< 0.001). The prevalence of heavy drinkers was the highest among the roofless participants (40%). CONCLUSIONS Homeless people have much poorer health and they utilize health services less than the most disadvantaged quintile of the general population. There is a clear social gradient within the homeless population, as well, which calls for integrated approaches for specific interventions to improve their health.
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Affiliation(s)
- Emese Nagy-Borsy
- Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, Pécs, 7624, Hungary
| | - Zsolt Vági
- Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, Pécs, 7624, Hungary
| | - Petra Skerlecz
- Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, Pécs, 7624, Hungary
| | | | - István Kiss
- Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, Pécs, 7624, Hungary
| | - Zsuzsa Rákosy
- Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, Pécs, 7624, Hungary.
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Sanko S, Eckstein M. Mobile Integrated Health Care in Los Angeles: Upstream Solutions to Mitigate the Covid-19 Pandemic. NEJM CATALYST 2021. [PMCID: PMC7817075 DOI: 10.1056/cat.20.0383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Innovative collaborations between a 911 emergency medical service (EMS) and local health care leaders helped foster a prehospital Mobile Integrated Health Care strategy that enhanced patient care while also mitigating the impact of Covid-19. Incorporating novel skill sets, alternate-destination pathways, safe and selective nontransport policies, and telehealth into upstream care has helped divert low-acuity patients from hospital EDs and optimally match patient need to location of care. In the City of Los Angeles, these strategies bought time for hospitals to stage for a patient surge, while the EMS bureau created the first Covid-19 testing sites for health care workers and, eventually, the public at large. Challenges such as cost, the need for increased medical oversight, EMS mission creep, and integrating this comprehensive EMS response into the community’s health care system have led to broader discussions with health care executives about unlocking the upstream value of prehospital patient navigation.
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Affiliation(s)
- Stephen Sanko
- Assistant Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Division of Emergency Medical Services, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Assistant Medical Director, Emergency Medical Services Bureau, Los Angeles Fire Department, Los Angeles, California, USA
| | - Marc Eckstein
- Professor of Emergency Medicine and Clinical Scholar, Department of Emergency Medicine, Division of Emergency Medical Services, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Medical Director and Commander, Emergency Medical Services Bureau, Los Angeles Fire Department, Los Angeles, California, USA
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