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Decker H, Colom S, Evans JL, Graham-Squire D, Perez K, Kushel M, Wick E, Raven MC, Kanzaria HK. Association of housing status and cancer diagnosis, care coordination and outcomes in a public hospital: a retrospective cohort study. BMJ Open 2024; 14:e088303. [PMID: 39266319 PMCID: PMC11404260 DOI: 10.1136/bmjopen-2024-088303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2024] Open
Abstract
OBJECTIVES Cancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a public hospital. DESIGN Retrospective cohort study examining new cancer diagnoses between 1 July 2011 and 30 June 2021. SETTING A public hospital in San Francisco. EXPOSURE Housing status (housed, formerly unhoused, unhoused) was ascertained via a county-wide integrated dataset that tracks both observed and reported homelessness. METHODS We reported univariate analyses to investigate differences in demographic and clinical characteristics by housing group. We then constructed Kaplan-Meier curves stratified by housing group to examine unadjusted all-cause mortality. Finally, we used multivariable Cox proportional hazards models to compare the hazard rate of mortality for each housing status group, adjusting for demographic and clinical factors. RESULTS Our cohort included 5123 patients with new cancer diagnoses, with 4062 (79%) in housed patients, 623 (12%) in formerly unhoused patients and 438 (9%) in unhoused patients. Unhoused and formerly unhoused patients were more commonly diagnosed with stage 4 disease (28% and 27% of the time, respectively, vs 22% of housed patients). After adjusting for demographic and clinical characteristics, unhoused patients with stage 0-3 disease had a 50% increased hazard of death (adjusted HR (aHR) 1.5, 95% CI 1.1 to 1.9; p<0.004) as did formerly unhoused patients (aHR 1.5, 95% CI 1.2 to 1.9; p=0.001) compared with housed individuals 3 months after diagnosis. CONCLUSIONS Unhoused and formerly unhoused patients diagnosed with non-metastatic cancer had substantially increased hazards of death compared with housed patients cared for in a public hospital setting. Current or former lack of housing could contribute to poor outcomes following cancer diagnoses via multiple mechanisms.
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Affiliation(s)
- Hannah Decker
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Sara Colom
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jennifer L Evans
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Kenneth Perez
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Internal Medicine, UCSF, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Maria C Raven
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hemal K Kanzaria
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Ramirez YV, Saltos GMD, Crawford TN. Exploring Correlates of Resource Insecurity Among Older Black or African Americans with HIV in Ohio. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02158-y. [PMID: 39230652 DOI: 10.1007/s40615-024-02158-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 08/23/2024] [Accepted: 08/25/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Resource insecurity is a social determinant of health that can impact people with HIV (PWH), in particular older African Americans (AA) or blacks with HIV. The purpose of this study was to identify resource insecurities among older Blacks or AA PWH specifically related to food and housing. Secondary focus was to find associations between resource insecurity and substance use history, stigma, and various forms of discrimination. METHODS Eligible participants (N = 52) of this cross-sectional study were 50 years old or older, identified as Black or AA, diagnosed with HIV, and living in Ohio. Food insecurity was assessed using the Household Food Insecurity Access Scale and housing insecurity was defined as not having stable housing. Resource insecurity was categorized into food and housing secure, food or housing insecure, and food and housing insecure. RESULTS Almost half (48.1%) of participants reported housing insecurity, with approximately 58.0% experiencing food insecurity, and 38.5% facing both. Current substance use, particularly opiates, showed significant association with resource insecurity (OR = 5.54; 95% CI = 1.91-17.30). Moreover, experiences of everyday (OR = 1.19; 95% CI = 1.10-1.30) or major forms (OR = 1.75; 95% CI = 1.33-2.39) of discrimination, as well as HIV stigma (OR = 1.24; 95% CI = 1.01-1.55), were also linked to increased odds of resource insecurity among participants. CONCLUSIONS Findings highlight how social factors contribute to resource insecurity among older AA PWH. Understanding the factors offers insight for targeted intervention in the fight against HIV transmission.
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Affiliation(s)
- Yanil V Ramirez
- Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | | | - Timothy N Crawford
- Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
- Wright State University Boonshoft School of Medicine, Population and Public Health Sciences, Dayton, OH, USA.
- Family Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
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Alston J, Baral S, Orkin A, Straus S. Réduire l’itinérance chez les personnes âgées au Canada. CMAJ 2024; 196:E918-E922. [PMID: 39074858 PMCID: PMC11286181 DOI: 10.1503/cmaj.231493-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Affiliation(s)
- Jillian Alston
- Division de médecine gériatrique (Alston, Straus), Hôpital St. Michael; Département de médecine (Alston), Université de Toronto; Programme d'application des connaissances (Baral), Institut du savoir Li Ka Shing, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département d'épidémiologie (Baral, Straus), École de santé publique Johns Hopkins, Baltimore, Md.; Département de médecine d'urgence (Orkin), Centre de santé Saint-Joseph, Réseau catholique de soins de santé de Toronto; Santé publique Ontario et École Dalla Lana de santé publique, Université de Toronto, Toronto, Ont.
| | - Stefan Baral
- Division de médecine gériatrique (Alston, Straus), Hôpital St. Michael; Département de médecine (Alston), Université de Toronto; Programme d'application des connaissances (Baral), Institut du savoir Li Ka Shing, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département d'épidémiologie (Baral, Straus), École de santé publique Johns Hopkins, Baltimore, Md.; Département de médecine d'urgence (Orkin), Centre de santé Saint-Joseph, Réseau catholique de soins de santé de Toronto; Santé publique Ontario et École Dalla Lana de santé publique, Université de Toronto, Toronto, Ont
| | - Aaron Orkin
- Division de médecine gériatrique (Alston, Straus), Hôpital St. Michael; Département de médecine (Alston), Université de Toronto; Programme d'application des connaissances (Baral), Institut du savoir Li Ka Shing, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département d'épidémiologie (Baral, Straus), École de santé publique Johns Hopkins, Baltimore, Md.; Département de médecine d'urgence (Orkin), Centre de santé Saint-Joseph, Réseau catholique de soins de santé de Toronto; Santé publique Ontario et École Dalla Lana de santé publique, Université de Toronto, Toronto, Ont
| | - Sharon Straus
- Division de médecine gériatrique (Alston, Straus), Hôpital St. Michael; Département de médecine (Alston), Université de Toronto; Programme d'application des connaissances (Baral), Institut du savoir Li Ka Shing, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département d'épidémiologie (Baral, Straus), École de santé publique Johns Hopkins, Baltimore, Md.; Département de médecine d'urgence (Orkin), Centre de santé Saint-Joseph, Réseau catholique de soins de santé de Toronto; Santé publique Ontario et École Dalla Lana de santé publique, Université de Toronto, Toronto, Ont
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Bowman GL, Moss A, Henry J, Swartwout K. Implementation of a Mental Health Nursing Practicum in an Urban Homeless Shelter. J Nurs Educ 2024:1-4. [PMID: 39038821 DOI: 10.3928/01484834-20240422-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND People experiencing homelessness suffer from deficient access to health care and disproportionately poor health outcomes. The American Association of Colleges of Nursing (AACN) maintains learning competencies for prelicensure nursing students. Shelters are rich environments for students to garner experiences with the inequities plaguing our health care system and to fulfill AACN competencies. METHOD We established a psychiatric and mental health nursing practicum at a homeless shelter. Following a retrospective pretest methodology, we evaluated student learning with the Health Care Professional's Attitudes Toward the Homeless Inventory (HPATHI). Students, faculty, and shelter staff provided qualitative feedback postpracticum. RESULTS Students' median HPATHI scores increased on 16 of 19 survey items. Qualitative feedback was largely positive and reinforced HPATHI data. CONCLUSION The practicum provided rich learning experiences for students. Educators establishing shelter-based practica should prioritize continuity, develop referral pathways for residents with illness, maintain a flexible mindset, administer prospective student surveys, and solicit feedback from shelter residents. [J Nurs Educ. 2024;63(X):XXX-XXX.].
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Patanwala MY, Garcia CM, Kushel M. Health Care for People Experiencing Homelessness. JAMA 2024; 332:70-71. [PMID: 38837140 DOI: 10.1001/jama.2024.5213] [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] [Indexed: 06/06/2024]
Abstract
This JAMA Insights examines the adverse effects of homelessness on physical and mental health and suggests strategies to improve access to health care, services, and housing for people experiencing homelessness.
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Affiliation(s)
- Maria Y Patanwala
- San Francisco Department of Public Health, San Francisco, California
| | - Cheyenne M Garcia
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
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Narayan A, Shah N, Hochman M. Beyond Brick and Mortar: The Rise of Street Medicine. J Gen Intern Med 2024:10.1007/s11606-024-08880-x. [PMID: 38937362 DOI: 10.1007/s11606-024-08880-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House's goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.
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Affiliation(s)
- Aditya Narayan
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Nirav Shah
- Stanford Clinical Excellence Research Center, Palo Alto, CA, USA
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Alston J, Baral S, Orkin A, Straus S. Tackling late-life homelessness in Canada. CMAJ 2024; 196:E662-E665. [PMID: 38772604 PMCID: PMC11104570 DOI: 10.1503/cmaj.231493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Affiliation(s)
- Jillian Alston
- Division of Geriatric Medicine (Alston, Straus), St. Michael's Hospital; Department of Medicine (Alston), University of Toronto; Knowledge Translation Program (Baral), Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ont.; Department of Epidemiology (Baral, Straus), Johns Hopkins School of Public Health, Baltimore, Md.; Department of Emergency Medicine (Orkin), St. Joseph's Health Centre, Unity Health Toronto; Dalla Lana School of Public Health (Orkin), University of Toronto, Toronto, Ont.
| | - Stefan Baral
- Division of Geriatric Medicine (Alston, Straus), St. Michael's Hospital; Department of Medicine (Alston), University of Toronto; Knowledge Translation Program (Baral), Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ont.; Department of Epidemiology (Baral, Straus), Johns Hopkins School of Public Health, Baltimore, Md.; Department of Emergency Medicine (Orkin), St. Joseph's Health Centre, Unity Health Toronto; Dalla Lana School of Public Health (Orkin), University of Toronto, Toronto, Ont
| | - Aaron Orkin
- Division of Geriatric Medicine (Alston, Straus), St. Michael's Hospital; Department of Medicine (Alston), University of Toronto; Knowledge Translation Program (Baral), Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ont.; Department of Epidemiology (Baral, Straus), Johns Hopkins School of Public Health, Baltimore, Md.; Department of Emergency Medicine (Orkin), St. Joseph's Health Centre, Unity Health Toronto; Dalla Lana School of Public Health (Orkin), University of Toronto, Toronto, Ont
| | - Sharon Straus
- Division of Geriatric Medicine (Alston, Straus), St. Michael's Hospital; Department of Medicine (Alston), University of Toronto; Knowledge Translation Program (Baral), Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ont.; Department of Epidemiology (Baral, Straus), Johns Hopkins School of Public Health, Baltimore, Md.; Department of Emergency Medicine (Orkin), St. Joseph's Health Centre, Unity Health Toronto; Dalla Lana School of Public Health (Orkin), University of Toronto, Toronto, Ont
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Kebeh M, Dlott CC, Tung WS, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Mental Health and Housing Status-Part Five of the Movement Is Life Special ONJ Series. Orthop Nurs 2024; 43:132-140. [PMID: 38861742 PMCID: PMC11178248 DOI: 10.1097/nor.0000000000001026] [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] [Indexed: 06/13/2024] Open
Abstract
Mental health and housing status have the potential to impact total joint arthroplasty (TJA) outcomes and are common TJA eligibility criteria that prevent patients from receiving surgery. Our aim was to formulate recommendations for how nurse navigators can assist patients with managing mental health and housing concerns. Through discussions with nurse navigators and a literature search across two databases, we gathered information regarding the optimization of mental health and housing status among TJA patients. We observed a lack of standardized protocols for addressing these concerns and literature supporting an increased focus on mental health and housing status, indicating the potential for greater nurse navigator involvement in developing and implementing protocols. We recommend nurse navigators use screening tools to identify mental health and housing concerns and offer the suggested resources to support patients in an effort to improve postoperative outcomes and decrease surgical risks.
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Affiliation(s)
- Martha Kebeh
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Wei Shao Tung
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Henwood BF, Kim BKE, Stein A, Corletto G, Suthar H, Adler KF, Mazzocchi M, Ip J, Padgett DK. Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness. Trials 2024; 25:290. [PMID: 38685123 PMCID: PMC11059706 DOI: 10.1186/s13063-024-08109-6] [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: 08/25/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group. METHODS Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months. RESULTS Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income. DISCUSSION This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population. TRIAL REGISTRATION ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).
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Affiliation(s)
- Benjamin F Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA.
| | - Bo-Kyung Elizabeth Kim
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Amy Stein
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Gisele Corletto
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Himal Suthar
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | - Julia Ip
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
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Carpenter C, O' Farrell A, Ní Áinle F, Ní Cheallaigh C, Kevane B. Retrospective cross-sectional analysis of concurrent VTE diagnosis in hospitalised socially excluded individuals in Ireland. BMJ Open 2024; 14:e073718. [PMID: 38216204 PMCID: PMC10806692 DOI: 10.1136/bmjopen-2023-073718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/17/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE Social exclusion (such as that experienced by people who are homeless, incarcerated or use drugs) increases morbidity across a range of diseases but is poorly captured in routine data sets. The aim of this study was to use a novel composite variable in a national-level hospital usage dataset to identify social exclusion and to determine whether social exclusion is associated with concurrent venous thromboembolism (VTE) in hospitalised patients in Ireland. Identifying and characterising this association in people who are socially excluded will inform VTE prevention and treatment strategies. DESIGN Retrospective cross-sectional study. SETTING Irish Hospital Inpatient Enquiry (HIPE) system, which collects diagnostic information by International Classification of Diseases Tenth Revision code on all hospital admission episodes in the Ireland. PARTICIPANTS All hospital admission episodes involving a VTE diagnosis (in a primary 'Dx 1' or secondary 'Dx 2-30' coding position) during a 12-month period in the Ireland were identified from consolidated, national-level datasets derived from the Irish HIPE system. Social exclusion was defined as the presence of one or more indicators of homelessness, drug use, incarceration, health hazards due to socioeconomic status or episodes of healthcare terminated prematurely. RESULTS Of 5701 admission episodes involving a VTE diagnosis (in a primary or secondary position) during the study period, 271 (4.8%) related to an individual affected by social exclusion. Among hospitalised individuals identified as being socially excluded based on the novel composite variable, the likelihood of having a concurrent VTE diagnosis was over twofold greater than that observed in the general population (OR 2.14, 95% CI 1.79 to 2.26; p<0.001). CONCLUSION These data suggest that VTE (primary and secondary) is over-represented in hospitalised socially excluded persons in Ireland and that the development of strategies to address this potentially life-threatening accompanying condition in this vulnerable patient group must be prioritised.
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Affiliation(s)
- Chloe Carpenter
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Anne O' Farrell
- Department of Statistics and Epidemiology, Health Intelligence Unit, HSE, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- School of Medicine, Trinity College, Dublin, Ireland
- Inclusion Health Service, St James's Hospital, Dublin, Ireland
| | - Barry Kevane
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Roth SE, Marsi K, Kenton N, Cohen-Cline H. Supporting Stabilization: A Qualitative Evaluation of a Pilot Program to Integrate Personal Caregiving Services Into Housing Settings. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241248084. [PMID: 38641977 PMCID: PMC11032059 DOI: 10.1177/00469580241248084] [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: 12/21/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/21/2024]
Abstract
Three organizations in Clark County, WA, partnered together to implement a pilot program to expand access to personal caregiving services in the homeless crisis response system. The aim of this study is to describe staff and clients' experiences of the program and its impact on clients' daily living activities, health and wellbeing, and housing stability. Using a qualitative descriptive design, semi-structured, in-depth interviews were conducted with 12 clients and 5 pilot staff, representing 4 housing service providers. Interviews were analyzed descriptively to examine staff and clients' perspectives and experiences with the personal care services pilot program. Caregivers helped clients establish routines, find companionship, and connect to health and social services both logistically and socioemotionally, supporting clients' stabilization and reducing barriers to healthcare. Hiring and retaining caregivers remained difficult due to the challenging nature of the work. Staff interviews highlight the need for additional supports to better retain caregivers. Findings from the evaluation have important implications for addressing the needs of individuals exiting homelessness and suggest that personal caregivers can play an important role in supporting the stabilization process. However, employing strategies such as training and increasing wages and benefits that support the needs of the caregiving workforce is essential to sustain this type of service delivery model.
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Rapaport P, Kidd G, Jeraldo RE, Mason A, Knapp M, Manthorpe J, Shulman C, Livingston G. A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives. BMC Geriatr 2023; 23:556. [PMID: 37700235 PMCID: PMC10498566 DOI: 10.1186/s12877-023-04250-0] [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: 05/12/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND The numbers of older people experiencing both homelessness and memory problems are growing, yet their complex health, housing and care needs remain undelineated and unmet. There is a critical gap in understanding what can improve the care, support and experiences of this group. In this qualitative study we explore how stakeholders understand memory problems among older people in the context of homelessness and consider what they judge gets in the way of achieving positive outcomes. METHOD We conducted reflexive thematic analysis of qualitative interviews (n = 49) using a semi-structured topic guide, with 17 older people (aged ≥ 50 years) experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners. We recruited participants from six homelessness hostels, one specialist care home and National Health and Local Authority Services in England. RESULTS We identified four overarching themes. The population is not taken seriously; multiple causes are hard to disentangle; risk of exploitation and vulnerability; and (dis)connection and social isolation. The transience and lack of stability associated with homelessness intensified the disorienting nature of memory and cognitive impairment, and those providing direct and indirect support required flexibility and persistence, with staff moving beyond traditional roles to advocate, provide care and safeguard individuals. Memory problems were perceived by frontline staff and older people to be overlooked, misinterpreted, and misattributed as being caused by alcohol use, resulting in pervasive barriers to achieving positive and desired outcomes. CONCLUSIONS Efforts to meet the needs of older people living with memory problems and experiencing homelessness and future interventions must reflect the complexity of their lives, often in the context of long-term alcohol use and current service provision and we make suggestions as to what could be done to improve the situation.
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Affiliation(s)
- Penny Rapaport
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK.
| | - Garrett Kidd
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Rosario Espinoza Jeraldo
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Ava Mason
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
- NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Caroline Shulman
- Pathway, London, UK
- Healthy London Partnership, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Gill Livingston
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
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13
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Zeien J, Vieira J, Hanna J, Ramirez A, Miller C, Hartmark-Hill J, Rosales C. Utilization of street-based COVID-19 vaccination clinics in Phoenix's homeless population. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023:2752535X231196415. [PMID: 37635377 DOI: 10.1177/2752535x231196415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
The novel Coronavirus (COVID-19) is a highly contagious viral illness that has caused the most significant global health crisis in recent human history. Individuals experiencing homelessness represent one of the more vulnerable populations for COVID-19 infection and morbidity. Amongst individuals experiencing homelessness in Phoenix, a student-led interprofessional organization called Street Medicine Phoenix (SMP) sought to both reduce the risk of COVID-19 transmission and morbidity/mortality related to infection. Through collaborations with the Maricopa County Department of Public Health and various community organizations, SMP developed a format for street-based vaccination clinics. SMP deployed these clinics on numerous occasions to the streets directly surrounding the community homeless shelter, allowing SMP to vaccinate individuals directly in their encampments. Through SMP's efforts starting in February 2021, 400 individuals experiencing homelessness have received at least one COVID-19 vaccine. Challenges encountered included low health literacy, lack of established rapport and trust, low vaccine confidence, difficulty verifying patients' vaccination status, difficulty obtaining sufficient information from patients to create a record in the Arizona State Immunization Information System (ASIIS), monitoring patients post-vaccination, transporting vaccine supplies from encampment to encampment, and lack of patient awareness of the mobile vaccine clinic services. Despite challenges, SMP's outreach efforts have demonstrated the feasibility and importance of mobile public health services to reach homeless encampments, particularly mobile vaccination clinics in response to disease outbreaks, and the necessity of strategic partnerships with community agencies to effectively meet the needs of underserved populations.
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Affiliation(s)
- Justin Zeien
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jaime Vieira
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Jeffery Hanna
- University of Arizona Mel and Enid Zuckerman College of Public Health, Phoenix, AZ, USA
| | - Alma Ramirez
- University of Arizona Mel and Enid Zuckerman College of Public Health, Phoenix, AZ, USA
| | - Catherine Miller
- University of Arizona Mel and Enid Zuckerman College of Public Health, Phoenix, AZ, USA
| | | | - Cecilia Rosales
- University of Arizona Mel and Enid Zuckerman College of Public Health, Phoenix, AZ, USA
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Johnson IM, Light MA. Pathways of Individuals Experiencing Serious Illness While Homeless: An Exploratory 4-Point Typology from the RASCAL-UP Study. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2023; 19:209-228. [PMID: 37331000 DOI: 10.1080/15524256.2023.2223772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The shifting age demographics of those experiencing homelessness in the United States expose shortcomings and barriers within homelessness response services and safety-net healthcare to address serious illness. The purpose of this study is to describe the common trajectories of patients concurrently experiencing homelessness and serious illness. As a part of the Research, Action, and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study, the study uses patient charts (n = 75) from the only specialty palliative care program in the U.S. specifically for people experiencing homelessness. Through a thematic mixed-method analysis, a four-point typology of care pathways taken by people experiencing homelessness while seriously ill is introduced: (1) aging and dying-in-place within the housing care system; (2) frequent transitions during serious illness; (3) healthcare institutions as housing; and (4) housing as palliation. Implications of this exploratory typology include targeted, site-specific interventions for supporting goal-concordant patient care and assisting researchers and policy makers in appreciating heterogeneity in experience and need among older and chronically ill people experiencing homelessness and housing precarity.
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Affiliation(s)
- Ian M Johnson
- University of Tennessee College of Social Work, Knoxville, Tennessee, USA
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15
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Fang ML, Canham SL, Battersby L. Supporting intersecting cultural needs of gender and age by increasing cultural safety and humility for Housing First initiatives. BMC Public Health 2023; 23:1005. [PMID: 37254119 PMCID: PMC10227820 DOI: 10.1186/s12889-023-15955-7] [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: 10/03/2022] [Accepted: 05/22/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND To sufficiently house and support persons experiencing homelessness (PEH), deeper understandings of the cultural appropriateness and responsiveness of community resources and the service delivery system is essential. In the case of Metro Vancouver, Canada, the cultural appropriateness and responsiveness of Housing First as a service model for supporting PEH was explored. METHODS Local service providers and stakeholders (n = 52) participated in three full day service-mapping workshops to identify Housing First supports for older adults, youth, and women experiencing homelessness, as part of a municipal-wide participatory and action-oriented study. Data were analyzed using a structured framework thematic analysis approach and cultural safety and humility lenses. RESULTS We generated three key themes: (i) insufficient built environments create challenges across gender and age, (ii) cultural safety and humility concerns at the intersection of gender and age, and (iii) implications for a culturally-responsive Housing First implementation. CONCLUSIONS Findings informed the development of a Culturally-Responsive Planning resource to support housing, health, and social service providers who are implementing Housing First initiatives.
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Affiliation(s)
- Mei Lan Fang
- School of Health Sciences, University of Dundee, City Campus, 11 Airlie Pl, Dundee, DD1 4HJ, UK.
- Department of Gerontology, Simon Fraser University, Burnaby, Canada.
| | - Sarah L Canham
- College of Social Work, College of Architecture and Planning, University of Utah, Salt Lake City, USA
| | - Lupin Battersby
- Knowledge Mobilization Hub, Simon Fraser University, Burnaby, Canada
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16
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Henwood BF, Semborski S, Pitts D, Niemiec SS, Yay O, Paone DL, Szanton SL. A pilot randomized controlled trial of CAPABLE in permanent supportive housing for formerly homeless adults. J Am Geriatr Soc 2023; 71:1587-1594. [PMID: 36661204 PMCID: PMC10693747 DOI: 10.1111/jgs.18235] [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: 09/19/2022] [Revised: 11/12/2022] [Accepted: 12/23/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND CAPABLE is a time-limited, evidence-based intervention that helps older adults live independently. It has not been previously tested for use among formerly homeless adults in permanent supportive housing (PSH) who experience accelerated aging that can jeopardize their ability to live independently and age in place. METHODS A pilot randomized controlled trial with PSH tenants with an average age of 63 years old was conducted to examine the impact of CAPABLE on basic and instrumental activities of daily living (ADL) (and other function-related parameters). Twenty-seven PSH tenants received the intervention and 30 PSH tenants were assigned to a waitlist control group. RESULTS Those who received the intervention showed improvements in five of seven health outcomes with small to medium effect sizes (Cohen's d = 0.20-0.47). When compared to the control group, the intervention group showed significantly greater improvements in two health outcomes-namely, reduction in limitations in instrumental ADL (p = 0.03) and depression (p = 0.01)-and greater effect sizes (d = 0.17-0.61). CONCLUSIONS CAPABLE is an evidence-based practice that can be successfully implemented in PSH to improve outcomes in a population that experiences significant health disparities and premature decline. Further investigation with a larger sample is warranted.
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Affiliation(s)
- Benjamin F. Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California (USC)
| | - Sara Semborski
- Suzanne Dworak-Peck School of Social Work, University of Southern California (USC)
| | - Deborah Pitts
- Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy, USC
| | | | - Ozan Yay
- Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy, USC
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17
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Henwood BF, Kuhn R, Padwa H, Ijadi-Maghsoodi R, Corletto G, Lawton A, Chien J, Bluthenthal R, Cousineau MR, Chinchilla M, Tran Smith B, Vickery KD, Harris T, Patanwala M, Akabike W, Gelberg L. Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study. JMIR Res Protoc 2023; 12:e46782. [PMID: 37115590 PMCID: PMC10150866 DOI: 10.2196/46782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. OBJECTIVE This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. METHODS People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. CONCLUSIONS Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. TRIAL REGISTRATION ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46782.
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Affiliation(s)
- Benjamin F Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Randall Kuhn
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, United States
| | - Howard Padwa
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
| | - Roya Ijadi-Maghsoodi
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Gisele Corletto
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Alex Lawton
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, United States
| | - Jessie Chien
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, United States
| | - Ricky Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Michael R Cousineau
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Melissa Chinchilla
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Bikki Tran Smith
- Department of Biomedical and Health Sciences, College of Nursing and Health Sciences, University of Vermont, Burlington, VT, United States
| | - Katherine D Vickery
- University of Minnesota Medical School, Minneapolis, MN, United States
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Taylor Harris
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Maria Patanwala
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Whitney Akabike
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, United States
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18
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O'Connor CMC, Poulos RG, Sharma A, Preti C, Reynolds NL, Rowlands AC, Flakelar K, Raguz A, Valpiani P, Faux SG, Boyer M, Close JCT, Gupta L, Poulos CJ. An Australian aged care home for people subject to homelessness: health, wellbeing and cost-benefit. BMC Geriatr 2023; 23:253. [PMID: 37106318 PMCID: PMC10139912 DOI: 10.1186/s12877-023-03920-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Older people subject to homelessness face many challenges including poor health status, geriatric syndromes, and depression, coupled with barriers in accessing health and aged care services. Many are in need of formal aged care at a younger age than the general population, yet, in Australia, specialised aged-care services to support this vulnerable cohort are limited. METHODS This study was an evaluation of a new purpose-built aged care home for people with high care needs and who are homeless or at risk of homelessness. Over the first 12 months post-admission, the study examined: (1) changes in residents' physical, mental, psychological and social health, and (2) the costs incurred by the study cohort, including any cost benefit derived. RESULTS Thirty-five residents enrolled in the study between March 2020 - April 2021. At admission, almost half of residents were within the range for dementia, the majority were frail, at high risk for falls, and had scores indicative of depression. Over time, linear mixed-effect models showed significant improvement in personal wellbeing scores, with clinically significant improvements in overall health related quality of life. Levels of physical functional independence, frailty, and global cognition were stable, but cognitive functional ability declined over time. Comparison of 12 month pre- and post- admission cost utility data for a smaller cohort (n = 13) for whom complete data were available, suggested an average per resident saving of approximately AU$32,000, while the QALY indicators remained stable post-admission. CONCLUSION While this was a small study with no control group, these preliminary positive outcomes add to the growing body of evidence that supports the need for dedicated services to support older people subject to homelessness.
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Affiliation(s)
- Claire M C O'Connor
- Centre for Positive Ageing, HammondCare, Sydney, Australia.
- School of Population Health, University of New South Wales, Sydney, Australia.
- School of Psychology, University of New South Wales, Sydney, Australia.
- Neuroscience Research Australia, Sydney, Australia.
| | - Roslyn G Poulos
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Anurag Sharma
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Costanza Preti
- Centre for Positive Ageing, HammondCare, Sydney, Australia
| | | | | | - Kyall Flakelar
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Angela Raguz
- Centre for Positive Ageing, HammondCare, Sydney, Australia
| | | | - Steven G Faux
- Departments of Rehabilitation Medicine and Pain Medicine, St Vincent's Hospital, Sydney, Australia
| | | | - Jacqueline C T Close
- Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Leena Gupta
- Sydney Local Health District, Sydney, Australia
| | - Christopher J Poulos
- Centre for Positive Ageing, HammondCare, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
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19
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Mantell R, Hwang YIJ, Radford K, Perkovic S, Cullen P, Withall A. Accelerated aging in people experiencing homelessness: A rapid review of frailty prevalence and determinants. Front Public Health 2023; 11:1086215. [PMID: 37006541 PMCID: PMC10061143 DOI: 10.3389/fpubh.2023.1086215] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Older people experiencing homelessness (PEH) are a rapidly growing population at risk of accelerated aging and the early onset of geriatric conditions. One construct that shows promise in predicting age-related decline is frailty. Better understanding the rates and causes of frailty in PEH may improve understanding of its antecedents, thereby facilitating more targeted health and aged care service interventions. The aim of this study was to conduct a rapid review on the prevalence and determinants of frailty in adult PEH. Methods We conducted a rapid review of primary research papers studying PEH and frailty or frailty-related concepts. Results Fourteen studies were included, which indicate that frailty presents earlier and at higher rates in PEH than community-dwelling cohorts. A notable difficulty for many aging PEH was early-onset cognitive impairment which was associated with a range of negative functional outcomes. Another recurrent theme was the negative impact that drug and alcohol use and dependence can have on the health of PEH. Further, psychosocial and structural determinants such as loneliness, living in an impoverished neighborhood and being female had statistically significant associations with frailty and functional decline in PEH. Discussion and implications PEH in their 40s and 50s can be frail and experience geriatric conditions, including cognitive impairment. Factors that have important relationships to frailty and functional decline in PEH include cognitive deficits, drug and alcohol dependence and loneliness, as well as upstream determinants such as gender and ethnicity. More targeted data and research on these factors, including cohort studies to better investigate their potentially causal effects, is important for researchers and practitioners assessing and treating frailty in PEH, particularly those interested in early intervention and prevention. Prospero registration ID CRD42022292549.
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Affiliation(s)
- Rhys Mantell
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Ye In Jane Hwang
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- UNSW Ageing Futures Institute, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Kylie Radford
- UNSW Ageing Futures Institute, University of New South Wales (UNSW), Sydney, NSW, Australia
- School of Psychology, Faculty of Science, University of New South Wales (UNSW), Sydney, NSW, Australia
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
| | - Silvija Perkovic
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Patricia Cullen
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Ngarruwan Ngadju: First Peoples Health and Wellbeing Research Centre, University of Wollongong, Wollongong, NSW, Australia
| | - Adrienne Withall
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- UNSW Ageing Futures Institute, University of New South Wales (UNSW), Sydney, NSW, Australia
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20
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Abstract
Context In recent years, cities across the world have seen widespread growth in unsheltered homelessness, in which a person sleeps in a place not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings. It is widely understood that people experiencing homelessness have poorer health outcomes than the general population. Less is known about the health of people who are unsheltered, yet they may be exposed to greater health risks than their sheltered counterparts. The purpose of this literature review is to evaluate and summarize the evidence on unsheltered homelessness and health. Evidence Acquisition A literature search was conducted using PubMed to identify publications on unsheltered homelessness and health. A total of 42 studies were included for review. Evidence Synthesis Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse than sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower healthcare utilization and often lack health insurance. Conclusions Evaluating the impact of shelter status on health outcomes has important implications for the allocation of housing and health services. Longitudinal studies are needed to examine the relationship between the duration of sheltered and unsheltered homelessness and health outcomes and explore the mediating mechanisms that lead to poor health among unsheltered populations. Despite these limitations, our results also suggest an urgent need to address the unique and severe challenges facing unsheltered populations and the need for intervention approaches that are sensitive to these unique disease burdens.
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Affiliation(s)
- Jessica Richards
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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21
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Fearn-Smith EM, Scanlan JN, Hancock N. Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3440. [PMID: 36834133 PMCID: PMC9966671 DOI: 10.3390/ijerph20043440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.
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Affiliation(s)
- Erin M. Fearn-Smith
- Faculty of Medicine and Health, Centre for Disability Research and Policy, The University of Sydney, Camperdown, NSW 2050, Australia
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22
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Stubbs JL, Jones AA, Wolfman D, Chan RCY, Vila-Rodriguez F, Vertinsky AT, Heran MK, Su W, Lang DJ, Field TS, Gicas KM, Woodward ML, Thornton AE, Barr AM, Leonova O, MacEwan W, Rauscher A, Honer WG, Panenka WJ. Differential age-associated brain atrophy and white matter changes among homeless and precariously housed individuals compared with the general population. BMJ Neurol Open 2023; 5:e000349. [PMID: 36660541 PMCID: PMC9843194 DOI: 10.1136/bmjno-2022-000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
Background Homeless or precariously housed individuals live with poor health and experience premature mortality compared with the general population, yet little is known about age-related brain changes among these individuals. We evaluated whether MRI measures of brain structure are differentially associated with age and selected risk factors among individuals who are homeless or precariously housed compared with a general population sample. Methods We compared T1-weighted and diffusion tensor imaging measures of brain macrostructure and white matter microstructure in a well-characterised sample of 312 precariously housed participants with a publicly available dataset of 382 participants recruited from the general population. We used piecewise and multiple linear regression to examine differential associations between MRI measures and between the samples, and to explore associations with risk factors in the precariously housed sample. Results Compared with the general population sample, older age in the precariously housed sample was associated with more whole-brain atrophy (β=-0.20, p=0.0029), lower whole-brain fractional anisotropy (β=-0.32, p<0.0001) and higher whole-brain mean diffusivity (β=0.69, p<0.0001). Several MRI measures had non-linear associations with age, with further adverse changes after age 35-40 in the precariously housed sample. History of traumatic brain injury, stimulant dependence and heroin dependence was associated with more atrophy or alterations in white matter diffusivity in the precariously housed sample. Conclusions Older age is associated with adverse MRI measures of brain structure among homeless and precariously housed individuals compared with the general population. Education, improvements in care provision and policy may help to reduce the health disparities experienced by these individuals.
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Affiliation(s)
- Jacob L Stubbs
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Andrea A Jones
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Wolfman
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Ryan C Y Chan
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Fidel Vila-Rodriguez
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada
| | | | - Manraj K Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Wayne Su
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Donna J Lang
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada,Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | | | - Melissa L Woodward
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Allen E Thornton
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada,Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Olga Leonova
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada
| | - William MacEwan
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada
| | - Alexander Rauscher
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- Department of Psychaitry, University of British Columbia, Vancouver, BC, Canada,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada,British Columbia Neuropsychiatry Program, University of British Columbia, Vancouver, BC, Canada
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Zahir A, Yip D, Garcia C, Smith AN, Dhatt Z, Duke M, Kushel M. "I Needed for You to See What I'm Talking About": Experiences With Telehealth Among Homeless-Experienced Older Adults. Gerontol Geriatr Med 2023; 9:23337214231172650. [PMID: 37168020 PMCID: PMC10164854 DOI: 10.1177/23337214231172650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023] Open
Abstract
Little is known about how older adults with a current or recent experience of homelessness navigated the switch to telehealth during the COVID-19 pandemic. We examined the perceptions and use of telehealth in a purposive sample of 37 homeless-experienced older adults in mid-late 2020 through semi-structured qualitative interviews. We purposively recruited participants from a larger longitudinal study on homeless-experienced older adults in Oakland, CA. We subjected the data to content analysis. We found that most participants who used telehealth used audio-only phone calls for care. We found that (1) participants experienced challenges accessing the necessary technologies for telehealth, (2) perceptions of telehealth for physical health differed based on the modality (video vs. audio-only), and (3) participants had generally positive perceptions of telehealth for mental healthcare. Our findings suggest that clinicians interacting with homeless-experienced older adults should address the potential skepticism of audio-only telehealth patients, and assess their access to, and knowledge of, video conferencing technology.
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Affiliation(s)
- Ali Zahir
- University of California, San Francisco, San Francisco, USA
| | - Deborah Yip
- University of California, San Francisco, San Francisco, USA
| | - Cheyenne Garcia
- University of California, San Francisco, San Francisco, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
| | - Ashley Nicole Smith
- University of California, San Francisco, San Francisco, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
| | - Zena Dhatt
- University of California, San Francisco, San Francisco, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
| | - Michael Duke
- University of California, San Francisco, San Francisco, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
| | - Margot Kushel
- University of California, San Francisco, San Francisco, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
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24
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Porter NAC, Brosnan HK, Chang AH, Henwood BF, Kuhn R. Race and Ethnicity and Sex Variation in COVID-19 Mortality Risks Among Adults Experiencing Homelessness in Los Angeles County, California. JAMA Netw Open 2022; 5:e2245263. [PMID: 36472872 PMCID: PMC9856229 DOI: 10.1001/jamanetworkopen.2022.45263] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
Importance Few studies have used precise age-specific data to construct age-standardized estimates of the relative risks (RRs) of COVID-19 mortality for people experiencing homelessness (PEH) vs the general population, and none to date has addressed race and ethnicity and sex variations in COVID-19 mortality among PEH with COVID-19 infection. Objective To measure age-standardized mortality rate ratios for PEH vs the general population overall and by sex and race and ethnicity. Design, Setting, and Participants In this cross-sectional study, crude and age-specific COVID-19 mortality rates per 100 000 people were calculated using 5-year age groups and standardized mortality ratios for PEH and the general population aged 25 years and older, assessing differences by race and ethnicity and sex, from January 1, 2020, to November 1, 2021. Mortality and population estimates came from COVID-19 mandatory case reporting conducted by the Los Angeles County Department of Public Health, the annual point-in-time homeless count, and the US Census. Main Outcomes and Measures The main outcome was COVID-19 deaths sourced from clinician reports, death certificates, medical examiner reports, and vital records deaths. PEH status was determined using the US Department of Housing and Urban Development definitions for homelessness at the time of COVID-19 diagnosis or symptom onset. Results The study population included 25 441 deaths among an estimated 6 382 402 general population individuals and 256 deaths among an estimated 52 015 PEH. The race and ethnicity of the PEH sample was as follows: 15 539 Black (29.9%), 18 057 Hispanic (34.7%), 14 871 female (28.6%), 37 007 male (71.3%), and 3380 aged 65 years or older (6.5%), compared with the estimated general population of 6 382 402, which was 591 003 Black (9.3%), 2 854 842 Hispanic (44.7%), 3 329 765 female (52.2%), 3 052 637 male (47.8%), and 1 190 979 aged 65 years or older (18.7%). Crude death rates were 0.49% for PEH and 0.40% for the general population, but PEH experienced age-specific COVID-19 mortality risk 2.35 (95% CI, 2.08-2.66) times higher than the general population. There was significant risk associated with PEH status compared with their counterparts in the general population for Black PEH (RR, 1.69; 95% CI, 1.31-2.18), Hispanic PEH (RR, 2.34; 95% CI, 1.96-2.79), White PEH (RR, 8.33; 95% CI, 6.37-10.88), female PEH (RR, 3.39; 95% CI, 2.56-4.48), and male PEH (RR, 1.74; 95% CI, 1.52-2.00). Conclusions and Relevance This cross-sectional study of COVID-19 mortality among PEH with COVID-19 infection provides evidence suggesting excess risk of age-adjusted COVID-19 mortality among PEH compared with the general population. This study furthers understanding of the intersectional association between homelessness and race and ethnicity, as higher levels of mortality but narrower racial disparities among PEH than in the general population were observed.
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Affiliation(s)
- Natalie A. C. Porter
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles
| | | | - Alicia H. Chang
- Los Angeles Department of Public Health, Los Angeles, California
| | - Benjamin F. Henwood
- Dworak-Peck School of Social Work, University of Southern California, Los Angeles
| | - Randall Kuhn
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles
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25
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Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med 2022; 37:3611-3619. [PMID: 35167064 PMCID: PMC8853310 DOI: 10.1007/s11606-022-07438-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The homeless population is aging, with early onset of cognitive and functional impairments. It is unclear whether older homeless adults receive caregiving assistance that could prevent long-term disability. OBJECTIVE We describe characteristics of older homeless-experienced adults with caregiving need and determine factors associated with having unmet need. DESIGN AND PARTICIPANTS Cross-sectional analysis of a longitudinal study, Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME), examining health, life course events, and functional status among older homeless-experienced (i.e., currently and recently homeless) adults. We recruited 350 homeless adults (July 2013-June 2014) and an additional 100 (August 2017 to July 2018) in Oakland, California; this study includes 303 participants who completed caregiving interviews. MEASUREMENTS We defined caregiving need as difficulty with activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, Short Physical Performance Battery (SPPB) score < 10, or Modified Mini-Mental State (3MS) exam impairment. We defined unmet need as having caregiving need and reporting not receiving caregiving assistance in the last 6 months. Using logistic regression, we analyzed associations between respondent characteristics and unmet caregiving need. RESULTS Among 303 participants, the mean age was 61.3 ± 5.0 years; 73% were men and 82% were Black. Eighty-one percent had caregiving needs, and in 82% of those, their caregiving needs were unmet. Better self-rated health (AOR 2.13, CI [1.02-4.46], p = 0.04) and being a man (AOR 2.30, CI [1.12-4.69], p = 0.02) were associated with higher odds of unmet need. Moderate or high-risk substance use (AOR 0.47, CI [0.23, 0.94], p = 0.03) was associated with lower odds of unmet need. CONCLUSIONS Older homeless-experienced adults have high prevalence of unmet caregiving need. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term-care needs due to untreated disabilities.
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Affiliation(s)
- Wagahta Semere
- Division of General Internal Medicine, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
| | - Lauren Kaplan
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Karen Valle
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - David Guzman
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | | | - Cheyenne Garcia
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Margot Kushel
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
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26
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Mullady SSS, Castellanos S, Lopez L, Aguirre G, Weeks J, King S, Valle K, Goode C, Tsoy E, Possin K, Miller B, Kushel M, Lanata S. Neurocognitive health of older adults experiencing homelessness in Oakland, California. Front Neurol 2022; 13:905779. [PMID: 35937073 PMCID: PMC9353024 DOI: 10.3389/fneur.2022.905779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Background and objectives The homeless population in the US is aging. Cognitive impairment is prevalent in this population, yet little is known about the neurologic etiologies of such impairment. Addressing this gap in knowledge is important because homeless older adults with cognitive impairment due to neurodegenerative disease may need lifelong tailored support to obtain and maintain housing. In this study, we characterized the neurocognitive health of a sample of adults who experienced homelessness for the first time after age 50 using gold standard behavioral neurology examination practices. Methods We conducted a descriptive cross-sectional study of older adults who first experienced homelessness after age 50. We recruited our sample purposively from an ongoing longitudinal cohort study of adults who were aged 50 and over and homeless when they entered the cohort. For this sub study, we enrolled a convenience sample from those who reported their first episode of homelessness after age 50. We did not exclude individuals based on history of substance use. Neurologists conducted a structured neurocognitive history intake, neurological examination, neuropsychological evaluation, and functional assessment between November 2020 and February 2021. We screened all participants for neurocognitive disorders using gold standard clinical research diagnostic criteria. Results We evaluated 25 participants, most were men (76%) and Black (84%), with a median age of 61 years. The most common neurocognitive complaints included deficits in recent episodic memory (n = 15, 60%), executive functions (n = 13, 52%), and behavior/mood, with apathy being the most common complaint (n = 20, 80%). Neuropsychological testing revealed a high prevalence of socioemotional deficits (n = 20, 80%). Common neurological examination deficits included difficulties with coordination, such as impaired Luria task (n = 16, 64%), signs of distal peripheral neuropathy (n = 8, 32%), anosmia/hyposmia (n = 4, 21%), and signs of mild Parkinsonism (n = 5, 20%). The most common diagnoses were MCI (n = 7, 28%), bvFTD (n = 4, 16%), AD (n = 4, 16%), and DLB (n = 2, 8%). Discussion Our findings suggest that neurocognitive concerns and examination deficits are common among older homeless adults. Specific neurocognitive disorders may be overrepresented in this population, particularly frontotemporal disorders. Longitudinal studies involving brain biomarkers are needed to characterize the neurocognitive health of this vulnerable population more precisely.
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Affiliation(s)
- Sandeepa Satya-Sriram Mullady
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States,*Correspondence: Sandeepa Satya-Sriram Mullady
| | - Stacy Castellanos
- Department of Internal Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
| | - Lucia Lopez
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Gloria Aguirre
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - John Weeks
- Department of Internal Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
| | - Stephen King
- Department of Internal Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
| | - Karen Valle
- Department of Internal Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
| | - Collette Goode
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Elena Tsoy
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Katherine Possin
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Bruce Miller
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Margot Kushel
- Department of Internal Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
| | - Serggio Lanata
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States,Serggio Lanata
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27
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Fleming MD, Evans JL, Graham-Squire D, Cawley C, Kanzaria HK, Kushel MB, Raven MC. Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e2223891. [PMID: 35895061 PMCID: PMC9331083 DOI: 10.1001/jamanetworkopen.2022.23891] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/18/2022] [Indexed: 01/28/2023] Open
Abstract
Importance Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. Objective To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. Design, Setting, and Participants This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. Exposures SIP hotel placement with on-site supportive services. Main Outcomes and Measures The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. Results Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001). Conclusions and Relevance These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.
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Affiliation(s)
| | - Jennifer L. Evans
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Caroline Cawley
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
| | - Hemal K. Kanzaria
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
- Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Margot B. Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Maria C. Raven
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
- Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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28
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Knight KR, Weiser J, Handley MA, Olsen P, Weeks J, Kushel M. Temporary stays with housed family and friends among older adults experiencing homelessness: Qualitative findings from the HOPE HOME study. QUALITATIVE SOCIAL WORK : QSW : RESEARCH AND PRACTICE 2022; 21:542-558. [PMID: 35706979 PMCID: PMC9197090 DOI: 10.1177/14733250211012745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The proportion of adults age 50 and older experiencing homelessness is growing. People at risk for homelessness may stay with family and friends to prevent homelessness. Moving in with housed family and friends is a strategy used to exit homelessness. Little is known about these stays with family and friends. This study examined the motivations for and challenges of older adults experiencing homelessness staying with or moving in with family or friends. METHODS We purposively sampled 46 participants from the HOPE HOME study, a cohort of 350 community-recruited adults experiencing homelessness age ≥50 in Oakland, CA. Inclusion criteria included having stayed with housed family/friends for ≥1 nights in the prior 6 months. We sampled 19 family/friends who had hosted participants experiencing homelessness. We conducted separate, semi-structured interviews, summarized, memoed and coded data consistent using a grounded theory approach. RESULTS Older adults experiencing homelessness reported primarily temporary stays. Motivations for stays on the part of participants included a need for environmental, physical, and emotional respite from homelessness. Both individuals experiencing homelessness and hosts cited the mutual benefits of stays. Barriers to stays included feelings of shame, concerns about burdening the hosts, and interpersonal conflicts between older adults experiencing homelessness and host participants. CONCLUSIONS There are potential opportunities and concerns surrounding temporary stays between older adults experiencing homelessness and their family or friends. Policy solutions should support the potential mutual benefits of temporary stays, while addressing interpersonal barriers to strengthen kinship and friendship networks and mediate the negative impacts of homelessness.
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Affiliation(s)
- Kelly R Knight
- Department of Humanities and Social Sciences, University of California, San Francisco, CA, USA
| | - Jeremy Weiser
- School of Medicine, University of California, San Francisco, CA, USA
| | - Margaret A Handley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Pamela Olsen
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - John Weeks
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Margot Kushel
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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29
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Corey J, Lyons J, O’Carroll A, Stafford R, Ivers JH. A Scoping Review of the Health Impact of the COVID-19 Pandemic on Persons Experiencing Homelessness in North America and Europe. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3219. [PMID: 35328907 PMCID: PMC8954292 DOI: 10.3390/ijerph19063219] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 02/04/2023]
Abstract
Persons experiencing homelessness (PEH) are at heightened risk for infection, morbidity, and mortality from COVID-19. However, health consequences of the pandemic extend far beyond those directly caused by the virus. This scoping review aimed to explore the impacts of the COVID-19 pandemic on the health and well-being of PEH in North America and Europe. A systematic search of academic and grey literature was conducted in September 2021. To be included, studies had to include primary data related to the impact of the pandemic on health or well-being of PEH and be written in English. All potentially relevant references were independently screened by two reviewers, and minor conflicts were settled with input of a third reviewer. A total of 96 articles met criteria for inclusion. Data extraction was completed for all included studies, and findings synthesised and presented thematically. Numerous health impacts of the pandemic on PEH were identified, including SARS-CoV-2 infection, morbidity, mortality, and hospitalisation, fear of infection, access to housing, hygiene, PPE, food, as well as mental health, substance use, other health-related outcomes and treatment services. Gaps in the literature relating to persons using alcohol, access to mental health support, and violence were also identified. Implications for future research are discussed.
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Affiliation(s)
- Julia Corey
- Department of Public Health & Primary Care, School of Medicine, Trinity College Dublin, D24H74 Dublin, Ireland; (J.C.); (J.L.)
| | - James Lyons
- Department of Public Health & Primary Care, School of Medicine, Trinity College Dublin, D24H74 Dublin, Ireland; (J.C.); (J.L.)
| | | | - Richie Stafford
- HSE Community Healthcare Organisation Dublin North City & County, D09C8P5 Dublin, Ireland;
| | - Jo-Hanna Ivers
- Department of Public Health & Primary Care, School of Medicine, Trinity College Dublin, D24H74 Dublin, Ireland; (J.C.); (J.L.)
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30
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Cai C, Knight KR, Olsen P, Weeks J, Handley MA, Kushel MB. Barriers and Facilitators to Resolving Older Adult Homelessness through Stays with Family: Qualitative findings from the HOPE HOME Study. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2022; 32:200-209. [PMID: 38144397 PMCID: PMC10746129 DOI: 10.1080/10530789.2022.2035128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2023]
Abstract
Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.
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Affiliation(s)
- Christopher Cai
- University of California, San Francisco (UCSF) School of Medicine, 3333 California Street, Suite 485, San Francisco, CA USA 94143
| | - Kelly R. Knight
- Department of Humanities and Social Sciences, University of California, San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA USA 94143
| | - Pamela Olsen
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
| | - John Weeks
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
| | - Margaret A Handley
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
- Department of Epidemiology & Biostatistics, University of California, San Francisco, 550 16th St 2nd floor, San Francisco, CA USA 94158
| | - Margot B. Kushel
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
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Grammatikopoulou MG, Gkiouras K, Pepa A, Persynaki A, Taousani E, Milapidou M, Smyrnakis E, Goulis DG. Health status of women affected by homelessness: A cluster of in concreto human rights violations and a time for action. Maturitas 2021; 154:31-45. [PMID: 34736578 DOI: 10.1016/j.maturitas.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
Health problems of women experiencing homelessness are driven either from the usual background characteristics of this population, or from the homeless lifestyle. Apart from poverty and unemployment, transition to homelessness is often associated with substance abuse, history of victimization, stress, poor mental health and human immunodeficiency virus (HIV). Water insecurity can undermine bodily hygiene and dental health, posing a greater risk of dehydration and opportunistic infections. Exposure to extreme environmental conditions like heat waves and natural disasters increases morbidity, accelerates aging, and reduces life expectancy. Nutrition-wise, a high prevalence of food insecurity, obesity, and micronutrient deficiencies are apparent due to low diet quality and food waste. Poor hygiene, violence, and overcrowding increase the susceptibility of these women to communicable diseases, including sexually transmitted ones and COVID-19. Furthermore, established cardiovascular disease and diabetes mellitus are often either undertreated or neglected, and their complications are more widespread than in the general population. In addition, lack of medical screening and contraception non-use induce a variety of reproductive health issues. All these health conditions are tightly related to violations of human rights in this population, including the rights to housing, water, food, reproduction, health, work, and no discrimination. Thus, the care provided to women experiencing homelessness should be optimized at a multidimensional level, spanning beyond the provision of a warm bed, to include access to clean water and sanitation, psychological support and stress-coping strategies, disease management and acute health care, food of adequate quality, opportunities for employment and support for any minor dependants.
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Affiliation(s)
- Maria G Grammatikopoulou
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Nutritional Sciences and Dietetics, Faculty of Health Sciences, Alexander Campus, International Hellenic University, Thessaloniki, Greece
| | - Konstantinos Gkiouras
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aleks Pepa
- Department of Food Science and Human Nutrition, Agricultural University of Athens, Greece
| | | | - Eleftheria Taousani
- Department of Midwifery, Faculty of Health Sciences, International Hellenic University, Alexander Campus, Thessaloniki, Greece
| | - Maria Milapidou
- Dr. Juris, Post Doc Researcher, Faculty of Law, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Tong MS, Kaplan LM, Guzman D, Ponath C, Kushel MB. Persistent Homelessness and Violent Victimization Among Older Adults in the HOPE HOME Study. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:8519-8537. [PMID: 31135255 PMCID: PMC8715865 DOI: 10.1177/0886260519850532] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.
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Affiliation(s)
- Michelle S. Tong
- University of California, Berkeley, USA
- University of California, San Francisco, USA
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Kuhn R, Henwood B, Lawton A, Kleva M, Murali K, King C, Gelberg L. COVID-19 vaccine access and attitudes among people experiencing homelessness from pilot mobile phone survey in Los Angeles, CA. PLoS One 2021; 16:e0255246. [PMID: 34329350 PMCID: PMC8323924 DOI: 10.1371/journal.pone.0255246] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/12/2021] [Indexed: 12/05/2022] Open
Abstract
People experiencing homelessness (PEH) are at high risk for COVID-19 complications and fatality, and have been prioritized for vaccination in many areas. Yet little is known about vaccine acceptance in this population. The objective of this study was to determine the level of vaccine hesitancy among PEH in Los Angeles, CA and to understand the covariates of hesitancy in relation to COVID-19 risk, threat perception, self-protection and information sources. A novel mobile survey platform was deployed to recruit PEH from a federally qualified health center (FQHC) in Los Angeles to participate in a monthly rapid response study of COVID-19 attitudes, behaviors, and risks. Of 90 PEH surveyed, 43 (48%) expressed some level of vaccine hesitancy based either on actual vaccine offers (17/90 = 19%) or a hypothetical offer (73/90 = 81%). In bivariate analysis, those with high COVID-19 threat perception were less likely to be vaccine hesitant (OR = 0.34, P = 0.03), while those who frequently practiced COVID-19 protective behaviors were more likely to be vaccine hesitant (OR = 2.21, P = 0.08). In a multivariate model, those with high threat perception (AOR = 0.25, P = 0.02) were less likely to be hesitant, while those engaging in COVID-19 protective behaviors were more hesitant (AOR = 3.63, P = 0.02). Those who trusted official sources were less hesitant (AOR = 0.37, P = 0.08) while those who trusted friends and family for COVID-19 information (AOR = 2.70, P = 0.07) were more likely to be hesitant. Findings suggest that targeted educational and social influence interventions are needed to address high levels of vaccine hesitancy among PEH.
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Affiliation(s)
- Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Benjamin Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, United States of America
| | - Alexander Lawton
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Mary Kleva
- Akido Labs, Los Angeles, California, United States of America
| | - Karthik Murali
- Akido Labs, Los Angeles, California, United States of America
| | - Coley King
- Venice Family Clinic, Los Angeles, California, United States of America
| | - Lillian Gelberg
- Department of Family Medicine, University of California Los Angeles, Los Angeles, California, United States of America
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Lin LP, Wang LY, Wang TW, Chen YC, Lin JD. Factors Associated with Free Hospital Outpatient Service Use among Middle-Aged and Older Urban Homeless Adults in Taipei. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105330. [PMID: 34067784 PMCID: PMC8156856 DOI: 10.3390/ijerph18105330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022]
Abstract
Homeless individuals have many negative experiences with inequality regarding access to and the use of primary healthcare services, so policies to eliminate the disparities in and barriers to primary care access for these people are needed. The aim of this study was to explore the use and determinants of free hospital outpatient services for homeless people, in order to describe the provision of free healthcare policies for this vulnerable population in Taipei. One cross-sectional survey was conducted to recruit homeless people aged 45 years old and over in Taipei in 2018. A structured questionnaire was used, and face-to-face interviews were conducted by three social workers to collect the data. Finally, 129 participants were recruited in the study. The results show that 81.4% of the homeless people had made free hospital outpatient care visits (mean = 5.9 visits) in the last three months. An unadjusted logistic regression analysis showed that those homeless people who reported having usual healthcare providers, with higher depressive symptom scores, who used medication and had been hospitalized within one year, and had more chronic diseases, were significantly more likely to make free hospital outpatient visits. The adjusted logistic regression model indicates that homeless people with severe depressive symptoms (odds ratio (OR) = 9.32, 95% CI = 1.15–56.07), who had received medication (OR = 3.93; 95% CI = 1.06–14.52), and who had more than five chronic diseases (OR = 1.06, 95% CI = 1.35–13.27), were significantly more likely to make free hospital outpatient visits than their counterparts. The findings highlight that homeless people have higher healthcare requirements than the general population, and the healthcare system should pay more attention to factors associated with higher outpatient service use, such as homelessness, severe depressive symptoms, the receipt of medication and chronic diseases.
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Affiliation(s)
- Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Li-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Jin-Ding Lin
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence:
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Trick WE, Rachman F, Hinami K, Hill JC, Conover C, Diep L, Gordon HS, Kho A, Meltzer DO, Shah RC, Stellon E, Thangaraj P, Toepfer PS. Variability in comorbidites and health services use across homeless typologies: multicenter data linkage between healthcare and homeless systems. BMC Public Health 2021; 21:917. [PMID: 33985452 PMCID: PMC8117275 DOI: 10.1186/s12889-021-10958-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/04/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions. METHODS We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services). RESULTS Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple. CONCLUSIONS Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.
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Affiliation(s)
- William E Trick
- Health Research & Solutions, Center for Health Equity & Innovation, Cook County Health, Chicago, IL, USA.
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA.
| | | | - Keiki Hinami
- Health Research & Solutions, Center for Health Equity & Innovation, Cook County Health, Chicago, IL, USA
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jennifer C Hill
- Alliance to End Homelessness in Suburban Cook County, Hillside, IL, USA
| | - Craig Conover
- Medical Research Analytics and Informatics Alliance, Chicago, IL, USA
| | - Lisa Diep
- Health Research & Solutions, Center for Health Equity & Innovation, Cook County Health, Chicago, IL, USA
| | - Howard S Gordon
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic Healthcare, Chicago, IL, USA
- Section of Academic Internal Medicine Department of Medicine, and Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Abel Kho
- Center for Health Information Partnerships, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David O Meltzer
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Raj C Shah
- Department of Family Medicine and Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Ed Stellon
- Heartland Alliance Health, Chicago, IL, USA
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Markedly poor physical functioning status of people experiencing homelessness admitted to an acute hospital setting. Sci Rep 2021; 11:9911. [PMID: 33972563 PMCID: PMC8110541 DOI: 10.1038/s41598-021-88590-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/30/2021] [Indexed: 01/06/2023] Open
Abstract
Adults who are homeless experience poor health and frequently require hospital in-patient care but the physical functioning ability of this group is rarely considered. The objective of this study was to evaluate a broad range of physical functioning variables to enable better future planning of targeted health and accommodation services for this group. This cross-sectional, observational study was conducted in a large acute hospital in Dublin, Ireland. A comprehensive ward-based test battery evaluated physical functioning in 65 in-patients registered as homeless with an age range of 23-80 years. Less than 10% (n = 5) were > 70 years. 58/65 (83%) of participants had mobility limitations and 35/65 (54%) reported at least one fall in the previous six months. Only 25/66 (35%) were able to walk for 6 min and 20/65 (31%) were able to climb one flight of stairs. 45/63 (70%) of participants were pre-frail or frail. Muscular mass was normal in the majority of participants but grip strength was low. This study revealed hospital in-patients registered as homeless displayed particularly poor physical functioning levels and mobility regardless of age. Health and housing services should address the unmet physical functioning needs of this vulnerable group.
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Kiernan S, Mockler D, Ní Cheallaigh C, Broderick J. Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review. HRB Open Res 2021; 3:14. [PMID: 33728397 PMCID: PMC7934094 DOI: 10.12688/hrbopenres.13011.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Adults who are experiencing homelessness suffer higher levels of premature mortality and age-related medical conditions compared to the general population, but little is known about physical factors that influence their health experience. The aim of this scoping review was to evaluate what is known about physical functional limitations and physical activity levels and how they are measured in adults experiencing homelessness. Methods: This review was conducted in accordance with the Joanna Briggs Institute's methodology for scoping reviews. Suitable quantitative and qualitative articles were searched using PubMed, CINAHL, EMBASE, PsychInfo, Web of Science and SCOPUS databases using a combination of keywords and a gray literature search was performed. Two reviewers independently screened articles for inclusion. Inclusion criteria were studies that examined physical functional limitations and/or physical activity among homeless adults (with/without co-occurring mental illness, infectious disease, substance use disorder), as a primary or secondary outcome measure. Results: We identified 15 studies for inclusion including 2,018 participants. Studies were primarily quantitative (n=13) and there were 2 qualitative studies. The following outcomes related to physical functioning were reported; mobility levels (n=3), frailty (n=1), flexibility (n=2), strength (n=1), physical symptom burden (n=3), and exercise capacity (n=3). Eight studies reported outcomes related to physical activity. The majority of studies reported high levels of functional limitations among participants and low physical activity levels although a spectrum of abilities was noted. Conclusion: This review showed that many adults who are homeless appear to show a high burden of physical functional limitations and low physical activity levels but more objective and consistent measures should be applied to examine these factors in future studies. This will help address and plan future care, physical rehabilitation and housing needs for this vulnerable cohort. This scoping review will help direct research and future systematic reviews in this emerging area.
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Affiliation(s)
- Sinéad Kiernan
- Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Department of Physiotherapy, St. James's Hospital, Dublin, Ireland
| | - David Mockler
- John Stearne Medical Library, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- School of Medicine, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Department of Infectious Diseases, St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Julie Broderick
- Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland
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Broderick J, Kiernan S, Murphy N, Dowds J, Ní Cheallaigh C. Feasibility of a Broad Test Battery to Assess Physical Functioning Limitations of People Experiencing Homelessness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1035. [PMID: 33503869 PMCID: PMC7908183 DOI: 10.3390/ijerph18031035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND People who are homeless experience poor health. Reflective of overall health and factors such as acquired injuries, physical ability or functioning is often low among people who are homeless, but there is a lack of consistency of measures used to evaluate this construct. The aim of this study was to evaluate the feasibility of a broad test battery to evaluate limitations in physical functioning among people who are homeless. METHODS This cross-sectional, observational study occurred in a hospital in Dublin, Ireland. We evaluated lower extremity physical function (Short Physical Performance Battery), falls risk (timed up and go), functional capacity (six-minute walk test), stair-climbing ability (stair climb test), frailty (Clinical Frailty Scale), grip strength (handgrip dynamometer) and muscular mass (calf circumference measurement) in a population of people experiencing homelessness admitted for acute medical care. The test completion rate was evaluated for feasibility. RESULTS The completion rate varied: 65% (Short Physical Performance Battery), 55.4% (timed up and go), 38% (six-minute walk test), 31% (stair climb test), 97% (Clinical Frailty Scale), 75% (handgrip dynamometer), 74% (calf circumference measurement)). Collectively, the most common reasons for test non-participation were pain (24.1%, n = 40), not feeling well or able enough (20.1%, n = 33), and declined (11%, n = 18). CONCLUSION The feasibility of the test battery was mixed as test participation rates varied from 31% to 97%. Physical functioning tests need to be carefully chosen for people who are homeless as many standard tests are unsuitable due to pain and poor physical ability.
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Affiliation(s)
- Julie Broderick
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, University of Dublin, D08 W9RT Dublin, Ireland;
| | - Sinead Kiernan
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, University of Dublin, D08 W9RT Dublin, Ireland;
- Department of Physiotherapy, St. James’s Hospital, D08 X4RX Dublin, Ireland; (N.M.); (J.D.)
| | - Niamh Murphy
- Department of Physiotherapy, St. James’s Hospital, D08 X4RX Dublin, Ireland; (N.M.); (J.D.)
| | - Joanne Dowds
- Department of Physiotherapy, St. James’s Hospital, D08 X4RX Dublin, Ireland; (N.M.); (J.D.)
| | - Cliona Ní Cheallaigh
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, D08 W9RT Dublin, Ireland;
- Department of Infectious Diseases, St. James’s Hospital, Trinity College Dublin, D08 X4RX Dublin, Ireland
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Baggett TP, Scott JA, Le MH, Shebl FM, Panella C, Losina E, Flanagan C, Gaeta JM, Neilan A, Hyle EP, Mohareb A, Reddy KP, Siedner MJ, Harling G, Weinstein MC, Ciaranello A, Kazemian P, Freedberg KA. Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for Adults Experiencing Sheltered Homelessness During the COVID-19 Pandemic. JAMA Netw Open 2020; 3:e2028195. [PMID: 33351082 PMCID: PMC7756240 DOI: 10.1001/jamanetworkopen.2020.28195] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19). OBJECTIVE To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness. DESIGN, SETTING, AND PARTICIPANTS This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020. EXPOSURES Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention. MAIN OUTCOMES AND MEASURES Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented. RESULTS The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. CONCLUSIONS AND RELEVANCE In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.
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Affiliation(s)
- Travis P. Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Mylinh H. Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | | | - Elena Losina
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Policy and Innovation eValuation in Orthopedic Treatments Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Jessie M. Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Anne Neilan
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Emily P. Hyle
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
| | - Amir Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Krishna P. Reddy
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Mark J. Siedner
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of Witwatersrand, Johannesburg, South Africa
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Andrea Ciaranello
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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40
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Chodos AH, Cassel CK, Ritchie CS. Can the Safety Net be Age-Friendly? How to Address Its Important Role in Caring for Older Adults with Geriatric Conditions. J Gen Intern Med 2020; 35:3338-3341. [PMID: 32632790 PMCID: PMC7661593 DOI: 10.1007/s11606-020-06010-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/23/2020] [Indexed: 01/26/2023]
Abstract
The safety net, a collection of public hospitals, federally qualified health centers (FQHCs), and publicly funded community-based healthcare entities, provides essential care to middle-aged and older adults with geriatric conditions. The role of the safety net for these adults will intensify over the next two decades with the growing numbers of middle-aged and older adults with adverse social determinants of health and premature geriatric conditions. The foundation for addressing their needs is to detect geriatric conditions and then focus care plans on the impact of these factors on function, which predicts mortality and quality of life more than chronic conditions alone. To detect geriatric conditions in safety net populations, the Age-Friendly Health System (AFHS) framework offers an evidence-based focus on the 4Ms: Mentation, Mobility, Medications, and what Matters. Further incorporating geriatric care models that target the 4Ms and are adapted to safety net populations will enable age-friendly care that optimizes health and addresses what matters to older people.
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Affiliation(s)
- Anna Haseltine Chodos
- Division of Geriatric, Department of Medicine, University of California, San Francisco, CA, USA. .,Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA.
| | - Christine Karen Cassel
- Division of Geriatric, Department of Medicine, University of California, San Francisco, CA, USA
| | - Christine Seel Ritchie
- Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
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41
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Baggett TP, Scott JA, Le MH, Shebl FM, Panella C, Losina E, Flanagan C, Gaeta JM, Neilan A, Hyle EP, Mohareb A, Reddy KP, Siedner MJ, Harling G, Weinstein MC, Ciaranello A, Kazemian P, Freedberg KA. Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32817967 PMCID: PMC7430611 DOI: 10.1101/2020.08.07.20170498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance: Approximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. Objective: To assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. Design: We developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. Setting & Participants: Simulated cohort of 2,258 adults residing in homeless shelters in Boston. Interventions: We assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. Results: We simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions & Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Mylinh H Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Elena Losina
- Department of Biostatistics, Boston University School of Public Health, Boston, MA.,Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA.,Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jessie M Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA.,Section of General Internal Medicine, Boston University School of Medicine
| | - Anne Neilan
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Emily P Hyle
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Amir Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - Krishna P Reddy
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Mark J Siedner
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Department of Epidemiology and Harvard Center for Population & Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of Witwatersrand, South Africa
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Andrea Ciaranello
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, Cleveland, OH
| | - Kenneth A Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
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42
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Schaffer KB, Wang J, Nasrallah FS, Bayat D, Dandan T, Ferkich A, Biffl WL. Disparities in triage and management of the homeless and the elderly trauma patient. Inj Epidemiol 2020; 7:39. [PMID: 32654664 PMCID: PMC7358191 DOI: 10.1186/s40621-020-00262-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community. Methods A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed. Results Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates. Conclusions Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.
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Affiliation(s)
- Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Jiayan Wang
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Tala Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Anthony Ferkich
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
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43
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Affiliation(s)
- Jessie M Gaeta
- From the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Administration (K.E.W.), Boston Medical Center, the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Health Law, Policy, and Management (K.E.W.), Boston University Medical Center, the Boston Health Care for the Homeless Program (J.M.G., D.D.L.N., D.G.M.), the Department of Medicine, Massachusetts General Hospital (D.G.M.), and the Department of Medicine, Harvard Medical School (D.G.M.) - all in Boston
| | - Denise De Las Nueces
- From the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Administration (K.E.W.), Boston Medical Center, the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Health Law, Policy, and Management (K.E.W.), Boston University Medical Center, the Boston Health Care for the Homeless Program (J.M.G., D.D.L.N., D.G.M.), the Department of Medicine, Massachusetts General Hospital (D.G.M.), and the Department of Medicine, Harvard Medical School (D.G.M.) - all in Boston
| | - David G Munson
- From the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Administration (K.E.W.), Boston Medical Center, the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Health Law, Policy, and Management (K.E.W.), Boston University Medical Center, the Boston Health Care for the Homeless Program (J.M.G., D.D.L.N., D.G.M.), the Department of Medicine, Massachusetts General Hospital (D.G.M.), and the Department of Medicine, Harvard Medical School (D.G.M.) - all in Boston
| | - Joshua A Barocas
- From the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Administration (K.E.W.), Boston Medical Center, the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Health Law, Policy, and Management (K.E.W.), Boston University Medical Center, the Boston Health Care for the Homeless Program (J.M.G., D.D.L.N., D.G.M.), the Department of Medicine, Massachusetts General Hospital (D.G.M.), and the Department of Medicine, Harvard Medical School (D.G.M.) - all in Boston
| | - Kathleen E Walsh
- From the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Administration (K.E.W.), Boston Medical Center, the Departments of Medicine (J.M.G., D.D.L.N., J.A.B.) and Health Law, Policy, and Management (K.E.W.), Boston University Medical Center, the Boston Health Care for the Homeless Program (J.M.G., D.D.L.N., D.G.M.), the Department of Medicine, Massachusetts General Hospital (D.G.M.), and the Department of Medicine, Harvard Medical School (D.G.M.) - all in Boston
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Baggett TP, Racine MW, Lewis E, De Las Nueces D, O'Connell JJ, Bock B, Gaeta JM. Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston. Public Health Rep 2020; 135:435-441. [PMID: 32516035 DOI: 10.1177/0033354920936227] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
People experiencing homelessness are at high risk for coronavirus disease 2019 (COVID-19). In March 2020, Boston Health Care for the Homeless Program, in partnership with city and state public health agencies, municipal leaders, and homeless service providers, developed and implemented a citywide COVID-19 care model for this vulnerable population. Components included symptom screening at shelter front doors, expedited testing at pop-up sites, isolation and management venues for symptomatic people under investigation and for people with confirmed disease, quarantine venues for asymptomatic exposed people, and contact investigation and tracing. Real-time disease surveillance efforts in a large shelter outbreak of COVID-19 during the third week of operations illustrated the need for several adaptations to the care model to better respond to the local epidemiology of illness among people experiencing homelessness. Symptom screening was de-emphasized given the high number of asymptomatic or minimally symptomatic infections discovered during mass testing; contact tracing and quarantining were phased out under the assumption of universal exposure among the sheltered population; and isolation and management venues were rapidly expanded to accommodate a surge in people with newly diagnosed COVID-19. During the first 6 weeks of operation, 429 of 1297 (33.1%) tested people were positive for COVID-19; of these, 395 people were experiencing homelessness at the time of testing, representing about 10% of the homeless adult population in Boston. Universal testing, as resources permit, is a focal point of ongoing efforts to mitigate the effect of COVID-19 on this vulnerable group of people.
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Affiliation(s)
- Travis P Baggett
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.,2348 Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Melanie W Racine
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Elizabeth Lewis
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Denise De Las Nueces
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
| | - James J O'Connell
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.,2348 Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Barry Bock
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jessie M Gaeta
- 50960 Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
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45
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Abbs E, Brown R, Guzman D, Kaplan L, Kushel M. Risk Factors for Falls in Older Adults Experiencing Homelessness: Results from the HOPE HOME Cohort Study. J Gen Intern Med 2020; 35:1813-1820. [PMID: 31965522 PMCID: PMC7280424 DOI: 10.1007/s11606-020-05637-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/13/2019] [Accepted: 01/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND More than half of homeless adults are of age ≥ 50 years. Falls are a common cause of morbidity in older adults in the general population. Risk factors for falls in the general population include poor health, alcohol use, and exposure to unsafe environments. Homeless adults aged ≥ 50 have a high prevalence of known risk factors and face additional potential risks. OBJECTIVES To examine the prevalence of and risk of falling in a cohort of older homeless adults. DESIGN Longitudinal cohort study with participant interviews every 6 months for 3 years; data were analyzed using generalized estimating equations (GEEs). PARTICIPANTS Three hundred fifty adults aged ≥ 50, homeless at study entry, recruited via population-based sampling. MEASURES The dependent variable is any falls in prior 6 months; independent variables include individual (i.e., illness, behaviors) and social/environmental (i.e., social support, experiencing violence, living unsheltered) factors. RESULTS Over three quarters of participants were men (77.1%) and Black (79.7%). The median age was 58 (IQR 54, 61). At baseline, one third (33.7%) reported a fall in the prior 6 months. At follow-up visits, 23.1% to 31.2% of participants reported having fallen. In GEE models, individual risk factors (non-Black race, being a women, older age, functional impairment, urinary incontinence, history of stroke, and use of assistive devices, opioid, and marijuana) were associated with increased odds of falls. Environmental and social factors (spending any nights unsheltered (adjusted odds ratio (AOR) = 1.42, CI = 1.10-1.83) and experiencing physical assault (AOR = 1.67, CI = 1.18-2.37) were also associated. CONCLUSIONS Older homeless adults fall frequently. Likely contributors include having a high prevalence of conditions that increase the risk of falls, compounded by heightened exposure to unsafe environments. Fall prevention in this population should target those at highest risk and address modifiable environmental conditions. Providing shelter or housing and addressing substance use could reduce morbidity from falls in homeless older adults.
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Affiliation(s)
- Elizabeth Abbs
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Brown
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA.,Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, San Francisco, CA, USA
| | - David Guzman
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Lauren Kaplan
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Margot Kushel
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA.
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46
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Henwood BF, Rhoades H, Lahey J, Pynoos J, Pitts D, Brown RT. Examining fall risk among formerly homeless older adults living in permanent supportive housing. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:842-849. [PMID: 31815341 PMCID: PMC7124982 DOI: 10.1111/hsc.12915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 11/15/2019] [Accepted: 11/21/2019] [Indexed: 06/10/2023]
Abstract
Although permanent supportive housing (PSH) has been credited with a decline in the number of chronically homeless adults in the United States since 2007, the extent to which PSH can accommodate the needs of a prematurely aging population, including reducing the likelihood of falls, is unclear. The objective of this study is to examine the prevalence and correlates of falls with a sample of 237 tenants (45- to 80-year olds) from two PSH programmes in Los Angeles from 1 January 2017 to 10 August 2017. We also explore the location and severity of fall-related injury using a subsample of 66 tenants. Standard surveys queried demographics, health status, history of homelessness and falls. Multivariable logistic regression assessed the correlates of falling in the past year. More than half of the sample had fallen and more than 40% had multiple falls in the past year. Functional impairment, frailty and persistent pain were all associated with increased fall risk. For the 66 tenants who provided more detailed fall information, more than 40% fell at home and of those nearly half fell in their bathroom. Fall-related injuries were common, with more than one-third of the subsample experiencing serious injury. These findings suggest that fall prevention is needed in PSH but that more research is needed to understand the degree to which individual and environmental risk factors are contributing to falls.
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Affiliation(s)
- Benjamin F. Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California
| | - Harmony Rhoades
- Suzanne Dworak-Peck School of Social Work, University of Southern California
| | | | - Jon Pynoos
- Leonard Davis School of Gerontology, University of Southern California
| | - Deborah Pitts
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California
| | - Rebecca T. Brown
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania
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47
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Kiernan S, Mockler D, Ní Cheallaigh C, Broderick J. Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review. HRB Open Res 2020; 3:14. [PMID: 33728397 PMCID: PMC7934094 DOI: 10.12688/hrbopenres.13011.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 04/01/2024] Open
Abstract
Background: Adults who are experiencing homelessness suffer higher levels of premature mortality and age-related medical conditions compared to the general population, but little is known about physical factors that influence their health experience. This review aimed to evaluate what is known about physical functional limitations and physical activity levels, and how these constructs are measured in adults experiencing homelessness. Methods: This review was conducted in accordance with the Joanna Briggs Institute's methodology for scoping reviews. Suitable quantitative and qualitative articles were searched using PubMed, CINAHL, EMBASE, PsychInfo, Web of Science and SCOPUS databases using a combination of keywords and medical subject headings and a grey literature search was also performed. Two reviewers independently screened articles for inclusion. Inclusion criteria were studies that examined physical functional limitations and/or physical activity among homeless adults (with/without co-occurring mental illness, infectious disease, substance use disorder), as a primary or secondary outcome measure. Results: We identified 15 studies for inclusion including 2,018 participants. Studies were primarily quantitative (n=11) and there were 4 qualitative studies. The following physical focused measures were evaluated across studies; mobility levels (n=2), frailty (n=1), flexibility (n=2), strength (n=1), physical symptom burden (n=3), physical activity levels (n=6) and exercise capacity (n=3). The majority of studies reported high levels of functional limitations among participants and low physical activity levels although a spectrum of abilities was noted. Conclusion: This review showed that many adults who are homeless appear to show a high burden of physical functional limitations and low physical activity levels but more objective and consistent measures should be applied to examine these factors in future studies. This will help address and plan future care, physical rehabilitation and housing needs for this vulnerable cohort. This scoping review will help direct research and future systematic reviews in this emerging area.
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Affiliation(s)
- Sinéad Kiernan
- Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Department of Physiotherapy, St. James's Hospital, Dublin, Ireland
| | - David Mockler
- John Stearne Medical Library, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- School of Medicine, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Department of Infectious Diseases, St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Julie Broderick
- Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland
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48
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Kaplan LM, Sudore RL, Arellano Cuervo I, Bainto D, Olsen P, Kushel M. Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults. J Palliat Med 2020; 23:1300-1306. [PMID: 32182155 DOI: 10.1089/jpm.2019.0550] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background/Objectives: Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Design: Cross-sectional qualitative study. Setting: We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. Measurements: We conducted semistructured interviews with homeless-experienced older adults (n = 20) and focus groups with clinical stakeholders (n = 24) about perceived barriers and solutions to ACP engagement. Results: Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Conclusions: Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.
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Affiliation(s)
- Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - Dustin Bainto
- UC Berkeley-University of California, San Francisco Joint Medical Program, UC Berkeley School of Public Health, University of California, Berkeley, Berkeley, California, USA.,School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Pamela Olsen
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
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Padgett DK, Bond L, Gurdak K, Henwood BF. Eliciting Life Priorities of Older Adults Living in Permanent Supportive Housing. THE GERONTOLOGIST 2020; 60:60-68. [PMID: 31112594 PMCID: PMC7182008 DOI: 10.1093/geront/gnz040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adults who have experienced chronic homelessness are considered to be "old" by age 50 due to accelerated aging. While permanent supportive housing (PSH) has been found effective for these individuals, there is limited focus on the needs of adults "aging in place" in PSH. This study examined (1) how older adults in PSH identify and rank their life priorities, (2) how they describe these priorities in their own words, and (3) how life course adversity deepens an understanding of these priorities. RESEARCH DESIGN AND METHODS A convergent parallel mixed methods design was used in which qualitative case study analyses informed by a life course perspective provided a deeper understanding of how 14 older residents of PSH viewed their life priorities using quantitative card-sort rankings of 12 life domains. RESULTS Housing, family, mental health, physical health, and partner were the most frequently endorsed life priorities. Four themes emerged from the cross-case analyses: "aging in, aging out," "carefully restoring relationships," "life goes on," and "housing is fundamental." Convergent findings indicated that life adversity-social losses and interrupted lives-influenced both the high- and low-ranked card-sort priorities. DISCUSSION AND IMPLICATIONS This study demonstrated that participants were aware of their advancing years yet they sought to overcome adversity and losses through maintaining mental health and sobriety, improving physical health, and cautiously rebuilding relationships. As the numbers of older homeless rise, the inclusion of age-related services will be an important component of PSH services for residents as they age.
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Affiliation(s)
| | - Lynden Bond
- Silver School of Social Work, New York University
| | | | - Benjamin F Henwood
- Dworak-Peck School of Social Work, University of Southern California, Los Angeles
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Health Care Needs of Homeless Older Adults:: Examining the Needs of a Senior Center Cohort. Dela J Public Health 2019; 5:74-80. [PMID: 34467082 PMCID: PMC8389147 DOI: 10.32481/djph.2019.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives To assess the medical status and health care needs of Wilmington’s largest accessible group of homeless elders located at St. Patrick’s Center in order to identify areas for improvement of medical screening, preventive health care delivery, and disease management. Methods A cross sectional study was conducted between December 2016 and August 2018 at St. Patrick’s center in Wilmington, DE. Utilizing a structured health needs assessment, 64 unique individuals aged 50 years and older were interviewed. Descriptive statistics were used to compare data from homeless older adults with data from non-homeless older adults. Results Of the 64 total subjects, 17 self-reported as homeless at the time of interviewing. High rates of depressive and cognitive impairment symptoms were self-reported in both homeless and non-homeless participants. When compared to the non-homeless group at St. Patrick’s Center, the homeless cohort was less likely to have received a non-acute assessment (such as a routine physical exam/well check-up) or a routine dental cleaning/x-ray within the past year. Tobacco and alcohol use and were frequently self-reported by homeless and non-homeless respondents and were more frequent in the homeless group. The homeless individuals were more likely to have engaged in illicit drug use. Overall, more than 90% of the subjects had some form of health insurance coverage. The most frequently cited reasons for lack of healthcare were inability to afford co-payments/deductibles and lack of transportation. Conclusions To address the health care needs of this population, new programs to improve care should focus on facilitating access to services which address areas of deficiency. This group of older adults has benefited from a range of available services that reflect the work of a staff aware of their medical needs, as indicated by the high rate of insured individuals. Licit and illicit substance use assessment and treatment and dental screening remain areas of need for the homeless older adults interviewed in this study. The high rates of depression and cognitive impairment in both the homeless and non-homeless older adult groups suggest the need for further services in these areas as well. Access to care may be improved by addressing concerns regarding co-payments, deductibles, and transportation to care.
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