Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention

Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

BACKGROUND

Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness.

OBJECTIVES

To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness.

SEARCH METHODS

Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022.

STUDY SELECTION

Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention.

RESULTS

The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness.

CONCLUSION

Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.

The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

Effectiveness of a peer-supported crisis intervention to reduce the proportion of compulsory admissions in acute psychiatric crisis interventions in an outreach and outpatient setting: study protocol for an exploratory cluster randomised trial combined with qualitative methods

INTRODUCTION

Compulsory admissions are associated with feelings of fear, humiliation and powerlessness. The number of compulsory admissions in Germany and other high-income countries has increased in recent years. Peer support has been shown to increase the self-efficacy of individuals with mental health conditions in acute crises and to reduce the use of coercive measures in clinical settings. The objective of this study is to reduce the number of compulsory admissions by involving peer support workers (PSWs) in acute mental health crises in outreach and outpatient settings.

METHODS AND ANALYSIS

This one-year intervention is an exploratory, cluster randomised study. Trained PSWs will join the public crisis intervention services (CIS) in two of five regions (the intervention regions) in the city of Bremen (Germany). PSWs will participate in crisis interventions and aspects of the mental health services. They will be involved in developing and conducting an antistigma training for police officers. The remaining three regions will serve as control regions. All individuals aged 18 and older who experience an acute mental health crisis during the operating hours of the regional CIS in the city of Bremen (around 2000 in previous years) will be included in the study. Semistructured interviews will be conducted with PSWs, 30 patients from control and intervention regions, as well as two focus group discussions with CIS staff. A descriptive comparison between all participants in the intervention and control regions will assess the proportion of compulsory admissions in crisis interventions during the baseline and intervention years, including an analysis of temporal changes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Bremen (file 2022-09) on 20 June 2022. The results will be presented via scientific conferences, scientific journals and communicated to policy-makers and practitioners.

TRIAL REGISTRATION NUMBER

DRKS00029377.

Homeless people's recovery in Housing First and Traditional Services: The role of working alliance in Italian housing services

This study aims to investigate whether a working alliance could represent a potential mechanism that explains the effectiveness of housing services in terms of user recovery, comparing the Housing First (HF) model with Traditional Services (TS). This study included 59 homeless service users in Italy (29 = HF; 30 = TS). Recovery was assessed upon entering the study (T0) and after 10 months (T1). Results indicate that participants inserted in HF services were more likely to report stronger working alliances with social service providers at T0 that, in turn, was directly associated with higher levels of users' recovery at the beginning of the study and indirectly (through recovery at T0) with recovery at T1. Implications of the results are discussed with respect to research and practice on homeless services.

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness

OBJECTIVE

Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto.

METHODS

The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest.

RESULTS

No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period.

CONCLUSIONS

In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.

Characteristics and Effectiveness of Co-Designed Mental Health Interventions in Primary Care for People Experiencing Homelessness: A Systematic Review

People experiencing homelessness (PEH) face a disproportionately high prevalence of adverse mental health outcomes compared with the non-homeless population and are known to utilize primary healthcare services less frequently while seeking help in emergency care facilities. Given that primary health services are more efficient and cost-saving, services with a focus on mental health that are co-designed with the participation of users can tackle this problem. Hence, we aimed to synthesize the current evidence of such interventions to assess and summarize the characteristics and effectiveness of co-designed primary mental healthcare services geared towards adult PEH. Out of a total of 10,428 identified records, four articles were found to be eligible to be included in this review. Our findings show that co-designed interventions positively impacted PEH's mental health and housing situation or reduced hospital and emergency department admissions and increased primary care utilization. Therefore, co-designed mental health interventions appear a promising way of providing PEH with continued access to primary mental healthcare. However, as co-designed mental health interventions for PEH can improve overall mental health, quality of life, housing, and acute service utilization, more research is needed.

The acceptability of financial incentives to support service engagement of adults experiencing homelessness and mental illness: a qualitative study of key stakeholder perspectives Authorship

PURPOSE

Evidence suggests financial incentives may effectively support service engagement among people experiencing homelessness, but literature related to their acceptability in this population is limited. This study used qualitative methods to explore stakeholder perspectives on the acceptability of using financial incentives to promote service engagement among homeless adults with mental illness.

METHODS

As part of a larger mixed-methods pragmatic trial of a community-based brief case management program in Toronto, Canada, twenty-two trial participants were purposefully recruited to participate in semi-structured qualitative interviews, and five service providers and seven key informants were purposefully recruited to participate in a focus group and interviews, respectively. Topics included perspectives of acceptability and lived experiences of using financial incentives to support engagement, health and well-being. Data collection occurred between April 2019 and December 2020. Data was audio-recorded and transcribed. Coding and interpretation of data was informed by grounded theory and inductive thematic analysis.

RESULTS

Stakeholders held diverse views on the acceptability of financial incentives to promote service engagement in this population. Main themes across groups included moralizing recipient motivation; tensions in how best to define and respect autonomy; and consideration of potential unintended consequences for both individuals and the service system. Significant group differences within some themes emerged.

CONCLUSION

Results highlight ongoing debates over using financial incentives to facilitate service engagement among adults experiencing homelessness and mental illness. Differences in stakeholder perspectives suggest the need for person-centredness in health and research settings, and balancing theoretical risks and long-term goals with likely potential for immediate benefits.

Health professionals' experience of implementing and delivering a 'Community Care' programme in metropolitan Melbourne: a qualitative reflexive thematic analysis

OBJECTIVES

To explore the experiences of health professionals involved in delivering a multidisciplinary Community Care programme that provides a transitional care coordination service for patients visiting a tertiary hospital service in Melbourne, Australia.

DESIGN

Reflexive thematic analysis was used to identify themes from descriptions of delivering the programme, including its perceived strengths and challenges.

PARTICIPANTS

12 healthcare professionals from four disciplines working in the Community Care programme were interviewed.

RESULTS

Four themes were identified: (1) 'increasingly complex', depicts the experience of delivering care to patients with increasingly complex health needs; (2) 'plugging unexpected gaps', describes meeting patient's healthcare needs; (3) 'disconnected', explains system-based issues which made participants feel disconnected from the wider health service; (4) 'a misunderstood programme', illustrates that a poor understanding of the programme within the health service is a barrier to patient enrolment which may have been exacerbated by a service name change.

CONCLUSIONS

The healthcare professionals involved in this study described the experience of providing care to patients as challenging, but felt they made a positive difference. By unravelling the patients' health problems in context of their surroundings, they were able to recognise the increasingly complex patients' health needs. The disconnection they faced to integrate within the wider healthcare system made their role at times difficult. This disconnection was partly contributed to by the fact that they felt the programme was misunderstood.

Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map

BACKGROUND

Experiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development.

METHODS

We followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity.

RESULTS

Twenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations.

DISCUSSION

We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.

Health and social outcomes in the Housing First model: Testing the theory of change

BACKGROUND

Homelessness continues to grow globally. The Housing First (HF) model offers immediate access to housing and support services without preconditions and has a growing body of evidence documenting its effectiveness at ending homelessness. HF has a robust theory of change that hypothesizes how unique program components (i.e., immediate access to housing, separation of services from housing, client choice, etc.) drive positive social and health changes over time. We advance the understanding of how HF causes client improvement by empirically testing this program's theory of change.

METHODS

Using a unique longitudinal quantitative data from the large Canadian At Home/Chez Soi Housing First trial we used path analysis to test the theory of change for Quality of Life, Crisis related events or service utilization, and Recovery.  Program pathways and health and social outcomes were measured at enrolment, 6-, 12- and 24-months post-enrolment.

FINDINGS

Most hypothesized pathways were confirmed with path analysis.  Confirmed pathways for two outcomes- Quality of Life (QOL) and Recovery - were similar. Health and social consultations at enrolment, health status at 6- and 12-months post enrolment, and social connectedness at 12-months were important predictors of the 24-month outcomes of Quality of Life and Recovery, but not for Crisis related events or service utilization.

INTERPRETATION

This analysis directly responds to recent calls for more empirical evidence about intervention mechanisms. Ensuring linkages to health and social service consultations for clients, supporting clients' engagement with family and community, and enabling clients to improve or maintain good health will drive better longer term client outcomes within Housing First.

FUNDING

Funding Mental Health Commission of Canada.

Factors That Influence Quality of Life in People Experiencing Homelessness: A Systematic Mixed Studies Review

BACKGROUND

An emerging category of morbidity in research among people experiencing homelessness (PEH) is quality of life (QoL). The Commission on Social Determinants of Health (CSDH) framework was used to explain the relationship between the resulting factors and their impact on QoL among PEH.

AIMS

The purpose of this systematic mixed studies review was to explore the factors that are associated with QoL among homeless individuals.

METHOD

A systematic mixed studies review was conducted using CINAHL, Medline, PubMed, and SocIndex databases. Quantitative, qualitative, and mixed methods studies were included and synthesized employing results-based convergent synthesis design.

RESULTS

The initial search resulted in 757 studies with 55 studies meeting the inclusion criteria. Thematic analysis revealed themes influencing QoL among PEH categorized by the CSDH determinants of structural, social cohesion and social capital, and intermediary determinants. Among these themes, higher social status, strong relationships, better reported physical and mental health, and a positive life outlook were associated with increased QoL. Social isolation, substance use, poorer life outlook, increased years spent homeless, and perceived quality of housing were associated with decreased QoL. Age, sex, and housing programs revealed inconsistent results on QoL.

CONCLUSIONS

While the factors presented in this review indicate some consistent relationships with QoL in PEH, this review has shown QoL among this population is complex and multifactorial. Future research should focus on relationships between the CSDH determinants, particularly the psychosocial factors and the QoL priorities defined by PEH, and how they may influence QoL among PEH.

Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study

Background

Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges.

Methods

We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed.

Results

From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges.

Conclusions

A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.

Using financial incentives to support service engagement of adults experiencing homelessness and mental illness: A qualitative analysis of key stakeholder perspectives

Introduction

Homelessness and mental illness are associated with poor service engagement, health and health service use outcomes. Existing literature suggests that financial incentives may effectively support service engagement of this population, but studies investigating key stakeholder perspectives are lacking. This study aimed to elicit, using qualitative methods, nuanced service user and provider experiences by using financial incentives to support service engagement among adults experiencing homelessness and mental illness.

Methods

This qualitative study is part of a larger mixed‐methods pragmatic trial of financial incentives (Coordinated Access to Care for the Homeless—Financial Incentives [CATCH‐FI]) within a community‐based brief case management programme (CATCH) in Toronto, Ontario. Twenty‐two CATCH‐FI participants were purposefully recruited to participate in in‐depth, semi‐structured interviews; five CATCH service providers participated in a focus group and seven key informants in individual interviews. Data collection occurred between April 2019 and December 2020. All interviews and the focus group were audio‐recorded and transcribed. Topic guides prompted participant perspectives on and experiences of using financial incentives to support engagement, health and well‐being. Grounded theory and inductive thematic analysis guided coding and interpretation of transcripts. Triangulation and member‐checking enhanced the analytical rigour and validity of findings.

Results

CATCH service providers, key informants and subgroup of CATCH‐FI participants perceived financial incentives to directly facilitate service engagement. The majority of CATCH‐FI participants however highlighted that intrinsic motivation and service quality may be relatively more important facilitators of engagement. Most study participants across stakeholder groups perceived that financial incentives have direct positive influences on health and well‐being in enabling access to basic needs and simple pleasures.

Conclusions

Our data suggest that for some adults experiencing homelessness and mental illness, financial incentives can directly support service engagement. In addition, financial incentives may positively impact health and well‐being by easing financial stress and enabling deeper attention to individual health needs. Further research on the effectiveness and acceptability of financial incentives is needed to improve understanding and uptake of a promising intervention to support health and health service use outcomes in an underserved population.

Patient or Public Contribution

Study participants provided input into the study research questions, study design, interview guides and interpretation of findings.

Evaluating the Impact of a Critical Time Intervention Adaptation on Health Care Utilization among Homeless Adults with Mental Health Needs in a Large Urban Center

OBJECTIVE

This study evaluated the impact of a critical time intervention (CTI) adaptation on health care utilization outcomes among adults experiencing homelessness and mental health needs in a large urban center.

METHODS

Provincial population-based administrative data from Ontario, Canada, were used in a pre-post design for a cohort of 197 individuals who received the intervention between January 2013 and May 2014 and were matched to a cohort of adults experiencing homelessness who did not receive the intervention over the same time period. Changes in health care utilization outcomes in the year pre- and postintervention were evaluated using generalized estimating equations, and post hoc analyses evaluated differences between groups.

RESULTS

Pre-post analyses revealed statistically significant changes in health care utilization patterns among intervention recipients, including reduced inpatient service use and increased outpatient service use in the year following the intervention compared to the year prior. However, the matched cohort analysis found nonsignificant differences in health service use changes between a subgroup of intervention recipients and their matched counterparts.

CONCLUSIONS

An adapted CTI model was associated with changes in health care utilization among people experiencing homelessness and mental health needs. However, changes were not different from those observed in a matched cohort. Rigorous study designs with adequate samples are needed to examine the effectiveness of CTI and local adaptations in diverse health care contexts.

Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Background

In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.

Methods

The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.

Results

There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.

Strengths and limitations

To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).

Future work

There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

The Impact of Financial Incentives on Service Engagement Among Adults Experiencing Homelessness and Mental Illness: A Pragmatic Trial Protocol

Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods (ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.

Quotidiano de equipes de consultório na rua: tecendo redes para a promoção da saúde

Resumo Objetivo compreender as potências e limites para a promoção da saúde de pessoas em situação de rua no quotidiano da equipe de Consultório na Rua. Método estudo de casos múltiplos holístico-qualitativo, fundamentado na Sociologia Compreensiva do Quotidiano, realizado com dois informantes-chave e 20 profissionais de equipe de Consultório na Rua de duas capitais do Sul do Brasil. Utilizou-se a Análise de Conteúdo Temática. Resultados as potências para a promoção da saúde de pessoas em situação de rua advêm da articulação da rede intrasetorial e intersetorial pela equipe de Consultório na Rua, além do vínculo e da redução de danos. Os limites enfrentados para desenvolver ações de promoção da saúde se deparam na especificidade e características desse público na terceirização da assistência social, na gestão, na política. Conclusões e implicações para a prática a promoção da saúde ainda é um desafio para a equipe a ser superado perante as demandas de agravos, o tratamento do adoecimento e a lógica biomédica. As estratégias intrasetoriais e intersetoriais podem ser estabelecidas para alcançar ações em rede e efetivamente promover saúde, contemplando direitos fundamentais à vida de pessoas em situação de rua, mesmo em um quotidiano com condições desfavoráveis de viver e conviver.

Health Care While Homeless: Barriers, Facilitators, and the Lived Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional Municipality

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

The effect of socio-demographic factors on mental health and addiction high-cost use: a retrospective, population-based study in Saskatchewan

OBJECTIVE

A small proportion of the population accounts for the majority of healthcare costs. Mental health and addiction (MHA) patients are consistently high-cost. We aimed to delineate factors amenable to public health action that may reduce high-cost use among a cohort of MHA clients in Saskatoon, Saskatchewan.

METHODS

We conducted a population-based retrospective cohort study. Administrative health data from fiscal years (FY) 2009-2015, linked at the individual level, were analyzed (n = 129,932). The outcome of interest was ≥ 90th percentile of costs for each year under study ('persistent high-cost use'). Descriptive analyses were followed by logistic regression modelling; the latter excluded long-term care residents.

RESULTS

The average healthcare cost among study cohort members in FY 2009 was ~ $2300; for high-cost users it was ~ $19,000. Individuals with unstable housing and hospitalization(s) had increased risk of persistent high-cost use; both of these effects were more pronounced as comorbidities increased. Patients with schizophrenia, particularly those under 50 years old, had increased probability of persistent high-cost use. The probability of persistent high-cost use decreased with good connection to a primary care provider; this effect was more pronounced as the number of mental health conditions increased.

CONCLUSION

Despite constituting only 5% of the study cohort, persistent high-cost MHA clients (n = 6455) accounted for ~ 35% of total costs. Efforts to reduce high-cost use should focus on reduction of multimorbidity, connection to a primary care provider (particularly for those with more than one MHA), young patients with schizophrenia, and adequately addressing housing stability.