Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States

Voices of the unhoused from Santa Fe, New Mexico: A mixed methods study of health status, substance use, and community harm reduction program perspectives

No published studies have examined the community service priorities and harm reduction perspectives of unhoused people in Santa Fe, New Mexico. We conducted a mixed methods pilot study of 56 unhoused people at community locations in Santa Fe to: (1) assess the current prevalence of chronic medical conditions and substance use; (2) highlight community service priorities; and (3) explore views of innovative community harm reduction programs. Our first hypothesis was there would be high prevalence of chronic medical conditions, for which we found high prevalence of post-traumatic stress disorder, major depression, substance use disorders, chronic pain, and hypertension. Our second hypothesis was that we would find top community service priorities of housing, food, and health care. We found long- and short-term housing and food, but not healthcare, top priorities. Our third hypothesis was that we would find mixed support for community harm reduction initiatives like managed alcohol programs and overdose prevention centers. We found positive, not mixed, support for these community harm reduction programs among Santa Fe's unhoused. Unhoused study participants ranged in age 27-77 years, with lifetime years unhoused from less than one year to 63 years. Study limitations included small sample size, convenience sampling, and descriptive results. Policies and program initiatives supporting additional Housing First options, managed alcohol programs, and overdose prevention centers in the Santa Fe community are clearly indicated to increase engagement with this vulnerable population. Future research should focus on inclusion of the perspectives of the unhoused in the design, conduct, evaluation, and dissemination of community programs to meet the needs of the unhoused, with re-defined outcomes to include changes in quality of life, program engagement, demarginalization, and future goals and plans, beyond currently utilized health and social service program outcome measures.

Diagnosis, Treatment, and Prevention of Tuberculosis Among People Experiencing Homelessness in the United States: Current Recommendations

OBJECTIVE

Tuberculosis (TB) is a public health problem, especially among people experiencing homelessness (PEH). The Advisory Council for the Elimination of Tuberculosis issued recommendations in 1992 for TB prevention and control among PEH. Our goal was to provide current guidelines and information in one place to inform medical and public health providers and TB programs on TB incidence, diagnosis, and treatment among PEH.

METHODS

We reviewed and synthesized diagnostic and treatment recommendations for TB disease and latent TB infection (LTBI) as of 2022 and information after 1992 on the magnitude of homelessness in the United States, the incidence of TB among PEH, the role of public health departments in TB case management among PEH, and recently published evidence.

RESULTS

In 2018, there were 1.45 million estimated PEH in the United States. During the past 2 decades, the incidence of TB was >10 times higher and the prevalence of LTBI was 7 to 20 times higher among PEH than among people not experiencing homelessness. TB outbreaks were common in overnight shelters. Permanent housing for PEH and the use of rapid TB diagnostic tests, along with isolation and treatment, reduced TB exposure among PEH. The use of direct observation enhanced treatment adherence among PEH, as did involvement of social workers to help secure shelter, food, safety, and treatment for comorbidities, especially HIV and substance use disorders. Testing and treatment for LTBI prevented progression to TB disease, and shorter LTBI regimens helped improve adherence. Federal agencies and the National Health Care for the Homeless Council have helpful resources.

CONCLUSION

Improvements in TB diagnosis, treatment, and prevention among PEH are possible by following existing recommendations and using client-centered approaches.

Hospitalization and Housing: A Qualitative Study Exploring the Perspectives of Hospitalized Patients Experiencing Housing Insecurity

Although housing insecurity has clear negative impacts on health, little is known about how it impacts patients' experience of hospitalization. In this qualitative study, we interviewed 22 hospitalized patients experiencing housing insecurity. The following three major themes emerged: 1) adverse social and environmental factors directly contribute to hospitalization, 2) lack of tailored care during hospitalization leaves patients unprepared for discharge, and 3) patients have difficulty recuperating after a hospital stay, leading to the risk of rehospitalization. Within these themes, participants described the roles of extreme physical and psychological hardship, chaotic interpersonal relationships, substance use, and stigma affecting participants' experiences before, during, and following hospitalization. Our results, based directly on the patient experience, suggest a need for hospital systems to invest in universal in-hospital screening for housing insecurity, incorporation of trauma-informed care, and robust partnerships with community organizations. Future research should explore the feasibility and impact of these interventions.

Occupational Therapy's Role in Chronic Conditions

It is the position of the American Occupational Therapy Association (AOTA) that occupational therapy practitioners are distinctly qualified to address the impact of chronic conditions on occupational performance and participation across the life span. The purpose of this position statement is twofold. First, it defines chronic conditions and describes the multiple factors associated with the development of one or more chronic conditions. Second, it provides an overview of how the field of occupational therapy has a distinct impact on improving the health and wellness of persons, groups, and populations with or at risk for chronic conditions through health promotion, disease prevention, and intervention.

Predictors of change in housing status over 12 months among individuals using emergency shelters, temporary housing or permanent housing in Quebec, Canada

Homelessness is an ongoing societal and public health problem in Canada and other countries. Housing services help homeless individuals along the transition towards stable housing, yet few studies have assessed factors that predict change in individual housing trajectories. This study identified predictors of change in housing status over 12 months for a sample of 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) or permanent housing (PH) resources in Quebec. Participants recruited from 27 community or public organisations were interviewed between January and September 2017, and again 12 months later. Sociodemographic variables, housing history, health conditions, service use and client satisfaction were measured. Directors and programme coordinators from the selected organisations also completed a baseline questionnaire measuring strictness in residential codes of living/conduct, interorganisational collaboration and overall budget. Independent variables were organised into predisposing, enabling and needs factors, based on the Gelberg-Andersen Behavioral Model. Multilevel logistic regressions were used to test associations with the dependent variable: change in housing status over 12 months, whether positive (e.g. shelter to TH) or negative (e.g. PH to shelter). Predictors of positive change in housing status were as follows: residing in PH, being female, having children (predisposing factors); having consulted a psychologist, higher frequency in use of public ambulatory services (enabling factors); and not having physical illnesses (needs factor). The findings support strategies for helping this clientele obtain and maintain stable housing. They include deploying case managers to promote access to public ambulatory services, mainly among men or individuals without children who are less likely to seek help; greater use of primary care mental health teams; the establishment of more suitable housing for accommodating physical health problems; and reinforcing access to subsidised PH programmes.

Nurse and case manager views on improving access and use of healthcare for adults living in permanent supportive housing

Housing is one of the social determinants of health, and homelessness is associated with health inequalities including increased morbidity and decreased life expectancy. Services to improve access to and use of primary healthcare are provided to formerly homeless individuals (hereafter residents) who live in permanent supportive housing (PSH). Residents do not always utilize services, nor receive adequate healthcare, and often have poor health outcomes. The study aims were to explore nurse and case manager (hereafter participants) views on the challenges of providing healthcare to residents, and strategies to address challenges. This descriptive, qualitative study used thematic analysis. Five nurses and eight case managers working with residents of PSH agencies were interviewed using semistructured interviews. Five main themes emerged. The first theme of context of healthcare use included how the residents' history of homelessness, trauma, and survival affected using services. The second theme was how aspects of relationships (communication issues and mistrust) were barriers to care. The third theme was how residents' health issues (physical chronic diseases, mental health, and substance dependency) affected care. Community level barriers (insurance, financial hardship, and transportation) was the fourth theme. The final theme highlighted recommendations to improve access and use of healthcare by building rapport, addressing mistrust, and using effective communication techniques. Participants noted that barriers to healthcare use were often influenced by residents' previous homeless experience. Nurses noted that chronic physical health issues were problematic for residents. Participants expressed the need to take time to form an authentic relationship to increase trust with residents.

A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services

Objective

To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county‐funded services.

Data Sources

Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county‐funded health care, jail and shelter, and mortality.

Study Design

We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county‐funded systems using multivariate regression analysis.

Data Collection

We extracted encounter data from an integrated database capturing health care at county‐funded facilities, shelter and jails, county housing placement, and death certificates.

Principal Findings

We enrolled 423 participants (199 intervention; 224 control). Eighty‐six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow‐up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died.

Conclusions

The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one‐third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high‐risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.

Toward Understanding Social Needs Among Primary Care Patients With Uncontrolled Diabetes

Introduction/Objectives:

Uncontrolled diabetes can lead to major health complications, and significantly contributes to diabetes-related morbidity, mortality, and healthcare costs. Few studies have examined the relationship between unmet social needs and diabetes control among predominantly Black and Hispanic patient populations.

Methods:

In a large urban hospital system in the Bronx, NY, 5846 unique patients with diabetes seen at a primary care visit between April 2018 and December 2019 completed a social needs screener. Measures included diabetes control (categorized as Hemoglobin (Hb) A1c <9.0 as controlled and Hb A1C ≥9.0 as uncontrolled), social needs (10-item screen), and demographic covariates, including age, sex, race/ethnicity, insurance status, percentage of block-group poverty, patient’s preferred language, and the Elixhauser Comorbidity Index.

Results:

Twenty-two percent (22%) of the patient sample had at least 1 unmet social need, and the most prevalent unmet social needs were housing issues (including housing quality and insecurity), food insecurity, and lack of healthcare transportation. Logistic regression analysis showed a significant relationship between social needs and uncontrolled diabetes, with more social needs indicating a greater likelihood of uncontrolled diabetes (Adjusted Odds Ratio (AOR) for ≥3 needs: 1.59, 95% CI: 1.26, 2.00). Of the patients with most frequently occurring unmet social needs, lack of healthcare transportation (AOR: 1.54, 95% CI: 1.22, 1.95) and food insecurity (AOR: 1.50, 95% CI: 1.19, 1.89) had the greatest likelihood of having uncontrolled diabetes, after adjusting for covariates.

Conclusion:

Unmet social needs appear to be linked to a greater likelihood of uncontrolled diabetes. Implications for healthcare systems to screen and address social needs for patients with diabetes are discussed.

Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health

US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.