Perceptions of health and health service utilization among homeless and housed psychiatric consumer/survivors

Health-seeking behaviours in the homeless population: A concept analysis

This concept analysis aims to define the concept of health-seeking behaviour in relation to the homeless population. The altered experiences of individuals who are homeless suggest that the concept of health-seeking behaviours has distinct attributes and therefore, a new definition of this concept is needed when compared with other populations. The framework outlined by Walker and Avant was used for this analysis with model, borderline and contrary cases. Databases searched were: CINAHL, Sociological Abstracts, PsycInfo, Google Scholar and PubMed. Because of the limited literature on the overall health-seeking behaviours of the homeless population, the most relevant 15 sources were selected from these databases for the literature review. Critical attributes derived from the literature were: (a) distrust in healthcare services, emerging from feelings of judgement or stigma from healthcare providers; (b) prioritising physiological needs such as food, shelter and clothing over the safety needs of health; (c) delaying seeking care until physical symptoms are severe; and (d) having decreased access to healthcare because of being uninsured or having no money, requiring transportation, experiencing long wait times for appointments, or lacking knowledge of available healthcare services. We define health-seeking behaviours in the homeless population as a complex process where a homeless individual seeks out healthcare for a problem or illness, but must first meet his or her physiological needs and then deem current symptoms severe enough to seek medical treatment despite his or her distrust in the healthcare system and barriers to accessing healthcare. Homeless individuals may face unique physiological hardships and emotional stressors compared to the general population, which results in distinct attributes surrounding health-seeking behaviours. Healthcare providers need to be aware of current barriers to care and perceived access to care in order to reduce the barriers to care that the homeless population faces.

Mental Healthcare Utilization among Homeless People in the Greater Paris Area

The healthcare utilization of homeless people is generally considered insufficient, and studies often suffer from methodological bias (institutionalized vs. street samples). To adapt public health policies in France, epidemiological data on this population are scarce. The objective of this study was to analyze the use of psychiatric care by homeless people with mental health problems in the Greater Paris area and to define the factors influencing this use. The data were from the SAMENTA survey performed in 2009 with a representative random street sample of 859 homeless people from the Greater Paris area. The survey studied the use of psychiatric care (lifelong use, current follow-up, discontinuation of follow-up and treatment) and factors potentially associated with this use for people with a diagnosis of a psychotic, mood or anxiety disorder, with the diagnosis established with an original survey device. Because of our complex sampling design, we describe data for only a weighted estimated prevalence, weighted estimation of the number of people in the population (N) and unweighted total subgroup studied in the survey (n). Among 840 homeless people with useable data, 377 (N = 9762) had a psychiatric disorder. The use of whole-life care for these people may seem high, estimated at 68.7%, but few people were followed up for their disorders (18.2%); individuals with a psychotic disorder were more frequently followed up (36.5%) than others were (p < 0.05). Among those followed up (n = 86, N = 1760), 63.0% were taking medication. Access to care for these people seemed preserved, but the maintenance of care seemed problematic; indeed, among people with a lifelong whole use of care (n= 232, N = 6705), 72.3% could be considered to have discontinued care. The factors that improved lifetime health service utilization or follow-up were socio-demographic (age < 42 years, more educated), social (with social security coverage, not living in a hotel), and medical (psychotic disorder, personality disorder, suicide risk, somatic chronic illness, perception of mental suffering). Improving the care of homeless people with psychiatric disorders requires improving access to care for those isolated from the health system (in particular those living in hotels) and to guarantee continuity of care, by adapting the organization of the care system and promoting social rehabilitation.

Healthcare professionals' perceptions of the implementation of the transitional discharge model for community integration of psychiatric clients

Research has demonstrated the benefits of mental healthcare interventions that ensure a safe transition of clients throughout the discharge and community integration process. This paper reports on qualitative data from focus groups with health professionals collected as part of a larger a mixed method study designed to examine the effectiveness and sustainability of implementing the transitional discharge model. Data collection involved two sets of focus groups, which were held at six months and one-year post-implementation. There were 216 health professional participants from nine (9) hospitals across the Province of Ontario, Canada. Data analysis used a four-step ethnographic framework by Leininger (1985) to identify descriptors and recurrent and major themes. The study identified four major themes, including healthcare professionals' roles and positive experiences in implementing the transitional discharge model; perceived benefits of the model; challenges to implementing the model; and suggestions for sustaining the model's implementation. Healthcare professionals felt that the implementation of the transitional discharge model has the potential for increasing their awareness of the process of clients' integration, serving as a framework for discharge planning, and reducing hospital readmissions. The study findings may provide healthcare providers with information on pragmatic ways to plan clients' discharge, to bridge the gap between hospital and community care, and to positively impact client health outcomes.

A Comparison of the Use of Physical and Mental Health Services by Homeless People With Severe Mental Health Problems in the Moncton Area Through the At Home/Chez Soi Program

The At Home / Chez Soi demonstration project was conducted to investigate the effectiveness of the Housing First model in 5 Canadian cities. Using a randomized controlled trial design, this study evaluates the impact of this project on the use of health services by people with severe and persistent mental health problems and a history of homelessness in the greater Moncton area. The sample comprised 193 homeless persons, 95 in the control group and 98 in the treatment group. The results show a significant difference between the 2 groups only in the number of days of hospitalization, particularly in the psychiatric unit. Factors associated with the use of health services by people who are homeless and who have severe mental health problems need to be further investigated.

Brief case management versus usual care for frequent users of emergency departments: the Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) randomized controlled trial

Background

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. This article describes the rationale for a brief case management intervention for frequent ED users with mental health and/or addiction challenges and the design of a randomized trial assessing its effectiveness.

Methods/Design

Eligible participants are adults in a large urban centre with five or more ED visits in the past year, with at least one prior visit for a mental health or addictions reason. Participants (N = 166) will be randomized to either 4 to 6 months of brief case management or usual care, and interviewed every 3 months for 1 year. Consent will be sought to access administrative health records. A subset of participants (N = 20) and service providers (N = 13) will participate in qualitative data collection.

Discussion

Addressing the needs of frequent ED users is a priority in many jurisdictions. This study will provide evidence on the effectiveness of brief case management, compared to usual care, on reducing ED visits among frequent ED users experiencing mental health or substance misuse problems, and inform policy and practice in this important area.

Trial registration

ClinicalTrials.gov Identifier: NCT01622244. Registered 4 June 2012.

A 10-year retrospective analysis of hospital admissions and length of stay among a cohort of homeless adults in Vancouver, Canada

Background

Homelessness is associated with a very high prevalence of substance use and mental disorders and elevated levels of acute health service use. Among the homeless, little is known regarding the relative impact of specific mental disorders on healthcare utilization. The aim of the present study was to examine the association between different categories of diagnosed mental disorders with hospital admission and length of stay (LOS) in a cohort of homeless adults in Vancouver, Canada.

Methods

Participants were recruited as part of an experimental trial in which participants met criteria for both homelessness and mental illness. Administrative data were obtained (with separate consent) including comprehensive records of acute hospitalizations during the 10 years prior to recruitment and while participants where experiencing homelessness. Generalized Estimating Equations were used to estimate the associations between outcome variables (acute hospital admissions and LOS) and predictor variables (specific disorders).

Results

Among the eligible sample (n = 433) 80 % were hospitalized, with an average of 6.0 hospital admissions and 71.4 days per person during the 10-year observation period. Of a combined total 2601 admissions to hospital, 1982 were psychiatric and 619 were non-psychiatric. Significant (p <0.001) independent predictors of hospital admission and LOS included a diagnosis of schizophrenia or bipolar disorder, as well as high (≥32 service contacts) non-psychiatric medical service use in the community.

Conclusions

Our results demonstrate that specific mental disorders alongside high non-psychiatric service use were significantly associated with hospital admission and LOS. These findings suggest the importance of screening within the homeless population to identify individuals who may be at risk for acute illness and the implementation of services to promote recovery and prevent repeated hospitalization.

Trial Registration

ISRCTN57595077; ISRCTN66721740

Qualitatively and quantitatively evaluating harm-reduction goal setting among chronically homeless individuals with alcohol dependence

INTRODUCTION

Most treatment programs for alcohol dependence have prioritized alcohol abstinence as the primary treatment goal. However, abstinence-based goals are not always considered desirable or attainable by more severely affected populations, such as chronically homeless people with alcohol dependence. Because these individuals comprise a multimorbid and high-utilizing population, they are in need of more focused research attention that elucidates their preferred treatment goals. The aim of this secondary study was therefore to qualitatively and quantitatively document participant-generated treatment goals

METHODS

Participants were currently or formerly chronically homeless individuals (N=31) with alcohol dependence who participated in a pilot of extended-release naltrexone and harm-reduction counseling. Throughout the treatment period, study interventionists elicited participants' goals and recorded them on an open-ended grid. In subsequent weeks, progress towards and achievement of goals was obtained via self-report and recorded by study interventionists. Conventional content analysis was performed to classify participant-generated treatment goals

RESULTS

Representation of the three top categories remained stable over the course of treatment. In the order of their frequency, they included drinking-related goals, quality-of-life goals and health-related goals. Within the category of drinking-related goals, participants consistently endorsed reducing drinking and alcohol-related consequences ahead of abstinence-based goals. Quantitative analyses indicated participants generated an increasing number of goals over the course of treatment. Proportions of goals achieved and progressed towards kept pace with this increase

CONCLUSIONS

Findings confirmed hypotheses that chronically homeless people with alcohol dependence can independently generate and achieve treatment goals towards alcohol harm reduction and quality-of-life improvement.

Vancouver At Home: pragmatic randomized trials investigating Housing First for homeless and mentally ill adults

BACKGROUND

Individuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented.

METHODS

Eligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data.

RESULTS

Participants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.

CONCLUSION

The study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).

Exploring the factors associated with youth homelessness and arrests

PROBLEM

The high rate of arrests among homeless youths has stimulated a growing interest in uncovering the factors associated with police involvement in this population. This study explored external factors related to their arrests.

METHOD

This secondary analysis involved 186 homeless youths. The difference between youths who reported arrests and those who did not was examined based on the following variables: economic status, meaningful activity, involvement with other homeless peers, mental illness, and drug use.

FINDINGS

The results of this study showed a significant association between drug use and arrests, length of time homeless and arrests, and depression and arrests.

CONCLUSION

The various factors thought to be associated with arrests likely interact with one another, making it difficult to directly link a specific behavior to being arrested.

Preventing homelessness after discharge from psychiatric wards: perspectives of consumers and staff

After spending time in the hospital, psychiatric clients are often discharged to homeless shelters or the streets, which can place a burden on health care systems. This study examined the effects of an intervention in which psychiatric clients from acute (n = 219) and tertiary (n = 32) sites were provided with predischarge assistance in securing housing. A program evaluation design was used to examine the effectiveness of the intervention. Qualitative data were available through interviews, focus groups, and monthly meetings. The results highlight several benefits of the intervention and show that homelessness can be reduced by connecting housing support, income support, and psychiatric care.

Perceptions of quality of life and disability in homeless persons with schizophrenia and persons with schizophrenia living in non-institutional housing

BACKGROUND

Homelessness is common in persons with schizophrenia. It is unclear how housing conditions and homelessness affect their quality of life and their disability.

AIMS

To explore the self-perceived quality of life and disability of homeless persons with schizophrenia and of those of persons with schizophrenia living in non-institutional housing.

METHODS

Seventy-six not-homeless and 50 homeless persons with schizophrenia were assessed using the World Health Organization's Quality of Life - short version (WHOQOL-Bref) and Disability Assessment Schedule (WHODAS-II). Univariate comparisons of the two groups were made for sociodemographic variables, clinical characteristics, perceived quality of life and disability. A regression model was used to adjust for potential confounding factors between quality of life, disability and housing.

RESULTS

After controlling for age, gender, marital status and age of first hospital admission, homeless persons had more positive scores for the quality of life domain 'health', for the disability domain 'getting along with people' and for the total disability score than persons in non-institutional housing.

CONCLUSION

Contrary to our expectations, the persons in non-institutional housing reported a lower quality of life and more disability than the homeless people. Future research should clarify whether non-institutional housing in and of itself can improve the well-being of people with schizophrenia.

Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

Background

The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.

Methods

Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.

Results

The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.

Conclusions

Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review

BACKGROUND

Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status.

METHODS

A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality.

RESULTS

Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations.

CONCLUSIONS

These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.

A 'snap shot' of the health of homeless people in inner Sydney: St Vincent's Hospital

Objectives. The poor health profile of people who are homeless results in a disproportionate use of health resources by these people. An in-hospital count of demographic and health data of homeless patients was conducted on two occasions at St Vincent’s Hospital in Sydney as an indicator of health resource utilisation for the Sydney region. Methods. Two in-hospital counts were conducted of homeless patients within the boundaries of St Vincent’s Hospital to coincide with the inaugural City of Sydney homeless street counts in winter 2008 and summer 2009. Data collected included level of homelessness, principal diagnosis, triage category, bed occupancy and linkages to services post hospital discharge. Results. Homeless patients at St Vincent’s utilised over four times the number of acute ward beds when compared with the state average. This corresponds to a high burden of mental health, substance use and physical health comorbidities in homeless people. There was high utilisation of mental health and drug and alcohol services by homeless people, and high levels of linkages with these services post-discharge. There were relatively low rates of linkage with general practitioner and ambulatory care services. Conclusion. Increasing knowledge of the health needs of the homeless community will assist in future planning and allocation of health services. What is known about the topic? The poor health status of people who are homeless has been previously noted in the USA, Canada and Scotland. What does this paper add? Homeless people living in Sydney also have a poor health profile and a disproportionate use of health resources when compared to people in the general population. What are the implications for practitioners? Health services for homeless people should be equipped to deal with mental health, substance use and physical health comorbidities.