Effect of Housing First on violence-related traumatic brain injury in adults with experiences of homelessness and mental illness: findings from the At Home/Chez Soi randomised trial, Toronto site

Unhoused and Injured: Injury Characteristics and Outcomes in Unhoused Trauma Patients

INTRODUCTION

The unhoused population is known to be at high risk for traumatic injury. However, there are scarce data regarding injury patterns and outcomes for this patient group. This study aims to investigate any differences in injury characteristics and hospital outcomes between unhoused and housed patients presenting with traumatic injuries.

METHODS

We conducted a 3-y retrospective cohort study at a level 1 trauma center in a metropolitan area with a large unhoused population. All adult trauma patients who were identified as unhoused or housed underinsured (HUI) were included in the study. Injury characteristics, comorbidities, and hospital outcomes were compared between the two groups.

RESULTS

A total of 8450 patients were identified, of which 7.5% were unhoused. Compared to HUI patients, unhoused patients were more likely to sustain minor injuries (65.2% versus 59.1%, P = 0.003) and more likely to be injured by assault (17.9% versus 12.4%, P < 0.001), stab wound (17.7% versus 10.8%, P < 0.001), and automobile versus pedestrian or bike (21.0% versus 15.8% P < 0.001). We found that unhoused patients had higher odds of mortality (adjusted odds ratio [AOR]: 1.93, 95% confidence interval [CI]: 1.10-3.36, P = 0.021), brain death (AOR: 5.40, 95% CI: 2.11-13.83, P < 0.001), bacteremia/sepsis (AOR: 4.36, 95% CI: 1.20-15.81, P = 0.025), and increased hospital length of stay (regression coefficient: 0.08, 95% CI: 0.03-0.12, P = 0.003).

CONCLUSIONS

This study observed significant disparities in injury characteristics and hospital outcomes between the unhoused and HUI groups. Our results suggest that these disparities are impacted by social determinants of health unique to the unhoused population.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review

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.

Rehabilitation among individuals with traumatic brain injury who intersect with the criminal justice system: A scoping review

Traumatic brain injury (TBI), a leading cause of morbidity and mortality globally, is highly prevalent among individuals who intersect with the criminal justice system (CJS). It is well-established that TBI negatively impacts individuals' interactions both within the CJS and upon release and is associated with serious disciplinary charges and higher recidivism rates. Although rehabilitation is fundamental to TBI recovery, it is not known to what extent rehabilitation is available to, or used by, individuals who intersect with the CJS. This scoping review explores the availability and extent of rehabilitation for individuals with TBI who intersect with the CJS, based on available literature. A systematic search of electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health), relevant organizations' websites, and reference lists of eligible articles identified 22 peer-reviewed articles and 2 gray literature reports that met predetermined eligibility criteria. Extracted data were synthesized through a descriptive numerical summary and qualitative content analysis. This review provides evidence that existing rehabilitation interventions are already serving individuals with TBI with a history of CJS involvement; however, they rarely consider or acknowledge TBI or CJS in their interventions. Findings also suggest opportunities to integrate rehabilitation for individuals with TBI who intersect with the CJS through TBI screening, education on TBI within CJS settings, and linkages to the community to facilitate continuity of care. This review also highlights significant gaps in knowledge regarding sex, gender, and other intersecting factors. Research to understand how these experiences impact the rehabilitation process throughout the CJS is urgently needed to enable timely and appropriate rehabilitation and continuity of care for diverse individuals with TBI who intersect with the CJS.

Rehabilitation among individuals experiencing homelessness and traumatic brain injury: A scoping review

Traumatic brain injury (TBI) is disproportionately prevalent among individuals experiencing homelessness. While rehabilitation is critical to facilitating recovery after TBI, there is currently limited information on the extent to which rehabilitation is provided to individuals experiencing homelessness and TBI. If unaddressed, this knowledge gap can perpetuate TBI-related challenges and contribute to a repetitive cycle of TBI and homelessness. This scoping review explored the extent to which rehabilitation, including the types of rehabilitation interventions, are available to, or used by, individuals experiencing homelessness and TBI. A systematic search of electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health) was conducted to identify peer-reviewed articles that met predetermined eligibility criteria. Gray literature and reference lists of eligible articles were also searched for relevant content. A descriptive numerical summary of extracted data was conducted, and qualitative analytic techniques were applied to analyze the data. Fifteen peer-reviewed articles and three gray literature reports were included, describing interventions for individuals experiencing homelessness and TBI (N = 4), rehabilitation for individuals experiencing homelessness without specific inclusion criteria for TBI (N = 11), and rehabilitation interventions that included individuals experiencing homelessness and TBI, without specific inclusion criteria for experiences of homelessness or TBI (N = 3). This review demonstrates that rehabilitation programs or interventions for this population already exist, and those that are focused on individuals experiencing homelessness are already serving individuals with TBI. Findings highlight opportunities to adapt existing rehabilitation for individuals who experience homelessness and TBI through screening for TBI, conducting cognitive and functional assessments, and tailoring interventions with multidisciplinary teams. Education and training for healthcare professionals working with individuals experiencing homelessness and TBI should be explored, including structured education and training, collaboration with a multidisciplinary team, and co-development of educational materials with service users. Research that considers the rehabilitation needs of diverse individuals experiencing homelessness and TBI is urgently needed.

Health Determinants among North Americans Experiencing Homelessness and Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) in those experiencing homelessness has been described in recent literature as a contributor to increased morbidity, decreased functional independence, and early mortality. In this systematically conducted scoping review, we aimed to better delineate the health determinants-as defined by Health Canada/Centers for Disease Control and Prevention (CDC)-associated with TBI in North Americans experiencing homelessness. BIOSIS, MEDLINE, CINAHL, EMBASE, SCOPUS, and Global Health were searched from inception to December 30, 2020. Gray literature search consisted of relevant meeting proceedings. A two-step process was undertaken, assessing title/abstract and full articles, respectively, based on inclusion/exclusion criteria, leading to the final 20 articles included in the review. Data were abstracted, assessing the aims, literature quality, and bias. Five health determinants displayed strong associations with TBI in those North Americans experiencing homelessness, including male gender, poor physical environment, negative personal health behaviors, adverse childhood experiences (ACEs), and low educational attainment. In those studies displaying a comparator population experiencing homelessness without TBI, the TBI group displayed trends toward increased disparity in Health Canada and CDC defined health determinants. Most studies suffered from moderate limitations. There are associations between male gender, poor physical environment, negative personal health behaviors, ACEs, and limited education in those experiencing homelessness and TBI. The results suggest that those experiencing homelessness with TBI in North America suffer poorer health consequences than those without TBI. Future research on TBI in North Americans experiencing homelessness should focus on health determinants as potential areas for intervention, which may lead to improved outcomes for those experiencing both homelessness and TBI.