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Christian NJ, Havlik J, Tsai J. The Use of Mobile Medical Units for Populations Experiencing Homelessness in the United States: A Scoping Review. J Gen Intern Med 2024; 39:1474-1487. [PMID: 38528232 PMCID: PMC11169337 DOI: 10.1007/s11606-024-08731-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/15/2024] [Indexed: 03/27/2024]
Abstract
With annual point-in-time counts indicating a rise in unsheltered homelessness in the United States, much attention has been paid to how to best provide care to this population. Mobile medical units (MMUs) have been utilized by many programs. However, little is known regarding the evidence behind their effectiveness. A scoping review is conducted of research on MMU provision of medical services for populations experiencing homelessness in the USA to examine the extent and nature of research activity, summarize available evidence, and identify research gaps in the existing literature. Following guidelines for scoping reviews, PubMed and Google Scholar were used to identify an initial 294 papers published from January 1, 1980, to May 1, 2023, using selected keywords, which were distilled to a final set of 50 studies that met eligibility criteria. Eligible articles were defined as those that pertain to the provision of healthcare (inclusive of dental, vision, and specialty services) to populations experiencing homelessness through a MMU in the United States and have been published after peer review. Of the 50 studies in the review, the majority utilized descriptive (40%) or observational methods (36%), with 4 review and 8 controlled studies and no completed randomized controlled trials. Outcome measures utilized by studies include MMU services provided (58%), patient demographics (34%), health outcomes (16%), patient-centered measures (14%), healthcare utilization (10%) and cost analysis (6%). The studies that exist suggest MMUs can facilitate effective treatment of substance use disorders, provision of primary care, and services for severe mental illness among people experiencing homelessness. MMUs have potential to provide community-based healthcare services in settings where homeless populations reside, but the paucity of randomized controlled trials indicates further research is needed to understand if MMUs are more effective than other care delivery models tailored to populations experiencing homelessness.
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Affiliation(s)
- Nicholaus J Christian
- Yale University School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - John Havlik
- Yale University School of Medicine, New Haven, CT, USA
| | - Jack Tsai
- Yale University School of Medicine, New Haven, CT, USA.
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Homeless Programs Office, U.S. Department of Veterans Affairs, Washington, DC, USA.
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
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Henwood BF, Kim BKE, Stein A, Corletto G, Suthar H, Adler KF, Mazzocchi M, Ip J, Padgett DK. Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness. Trials 2024; 25:290. [PMID: 38685123 PMCID: PMC11059706 DOI: 10.1186/s13063-024-08109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group. METHODS Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months. RESULTS Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income. DISCUSSION This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population. TRIAL REGISTRATION ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).
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Affiliation(s)
- Benjamin F Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA.
| | - Bo-Kyung Elizabeth Kim
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Amy Stein
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Gisele Corletto
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Himal Suthar
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | - Julia Ip
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
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Park S, Kim S, Kim HK, Tabarsi E, Hom B, Gallagher S, Ugarte C, Clark D, Schellenberg M, Martin M, Inaba K, Matsushima K. Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma. Am Surg 2024:31348241248691. [PMID: 38655755 DOI: 10.1177/00031348241248691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients. METHODS We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups. RESULTS A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks. CONCLUSIONS This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.
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Affiliation(s)
- Stephen Park
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Sean Kim
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Hye Kwang Kim
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Emiliano Tabarsi
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Brian Hom
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Shea Gallagher
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Chaiss Ugarte
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Damon Clark
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Matthew Martin
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
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Myers S, Kenzik K, Allee L, Dechert T, Theodore S, Jaffe A, Sanchez SE. Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital. Surg Infect (Larchmt) 2024; 25:101-108. [PMID: 38301176 DOI: 10.1089/sur.2023.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.
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Affiliation(s)
- Sara Myers
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Lisa Allee
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tracey Dechert
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sheina Theodore
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Abraham Jaffe
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Silver CM, Thomas AC, Reddy S, Kirkendoll S, Nathens AB, Issa N, Patel PP, Plevin RE, Kanzaria HK, Stey AM. Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America. JAMA Netw Open 2024; 7:e240795. [PMID: 38416488 PMCID: PMC10902734 DOI: 10.1001/jamanetworkopen.2024.0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024] Open
Abstract
Importance Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Avery B. Nathens
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nabil Issa
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Purvi P. Patel
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Chan SM, Wong H, Chen Y, Tang MYV. Determinants of depression and anxiety in homeless people: A population survey of homeless people in Hong Kong. Int J Soc Psychiatry 2023; 69:1145-1156. [PMID: 36734241 DOI: 10.1177/00207640231152208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are growing concerns about the homeless and mental health issues globally. This study aims to examine the mental health situation of homelessness and the determinants of anxiety and depression of them in Hong Kong. METHOD The data from the largest territory-wide study of the homeless population in 2021 was analyzed. Descriptive statistics and logistic regressions were used to investigate the association between mental health and socioeconomic variables, including demographic background, economic indicators, COVID-19 worries, government measures, and respect by others. The symptoms of depression and anxiety were assessed using Patient Health Questionnaire (PHQ) and General Anxiety Disorder (GAD). RESULTS The results showed that being female, food insecurity, and chronic diseases were the risk factors for anxiety and depression. A high level of respect by others was the protective factor for depression (adjusted OR 0.37, 95% CI [0.23, 0.61]) and anxiety (adjusted OR 0.40, 95% CI [0.24, 0.68]), compared to a low level of respect in the multivariate model. CONCLUSIONS Providing medical outreach services, additional resources for social services, implementation of homeless-friendly policies, and a progressive supply of public and transitional housing would help enhance the well-being of the homeless population.
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Affiliation(s)
- Siu-Ming Chan
- Department of Social and Behavioural Sciences, City University of Hong Kong, Hong Kong SAR, China
| | - Hung Wong
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yikang Chen
- Department of Educational Psychology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Mun-Yu Vera Tang
- Asia-Pacific Institute of Ageing Studies, Lingnan University, Hong Kong SAR, China
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Silver CM, Thomas AC, Reddy S, Sullivan GA, Plevin RE, Kanzaria HK, Stey AM. Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness. JAMA Netw Open 2023; 6:e2320862. [PMID: 37382955 PMCID: PMC10311388 DOI: 10.1001/jamanetworkopen.2023.20862] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/15/2023] [Indexed: 06/30/2023] Open
Abstract
Importance Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale. Objective To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission. Design, Setting, and Participants This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022. Exposures PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable. Main Outcomes and Measures The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment). Results A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19). Conclusions and Relevance Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lee JJ, Jagasia E, Wilson PR. Addressing health disparities of individuals experiencing homelessness in the U.S. with community institutional partnerships: An integrative review. J Adv Nurs 2023; 79:1678-1690. [PMID: 36882981 PMCID: PMC10182242 DOI: 10.1111/jan.15591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/26/2022] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
AIMS To examine existing community-institutional partnerships providing health care services to people experiencing homelessness by addressing social determinants of health (SDOH) at multiple socioecological levels. DESIGN Integrative review. DATA SOURCES PubMed (Public/Publisher MEDLINE), CINAHL (The Cumulative Index of Nursing and Allied Health Literature database), and EMBASE (Excerpta Medica database) were searched to identify articles on health care services, partnerships, and transitional housing. REVIEW METHODS Database search used the following keywords: Public-private sector partnerships, community-institutional relation, community-academic, academic community, community university, university community, housing, emergency shelter, homeless persons, shelter, and transitional housing. Articles published until November 2021 were eligible for inclusion. The Johns Hopkins Nursing Evidence-Based Practice Quality Guide was used to appraise the quality of articles included in the review by two researchers. RESULTS Seventeen total articles were included in the review. The types of partnerships discussed in the articles included academic-community partnerships (n = 12) and hospital-community partnerships (n = 5). Health services were also provided by different kinds of health care providers, including nursing and medical students, nurses, physicians, social workers, psychiatrists, nutritionists, and pharmacists. Health care services spanning from preventative care services to acute and specialized care services and health education were also made possible through community-institutional partnerships. CONCLUSION There is a need for more studies on partnerships that aim to improve the health of homeless populations by addressing social determinants of health at multiple socioecological levels of individuals who experience homelessness. Existing studies do not utilize elaborate evaluation methods to determine partnership efficacy. IMPACT Findings from this review highlight gaps in the current understanding of partnerships that seek to increase access to care services for people who experience homelessness. NO PATIENT OR PUBLIC CONTRIBUTION The results of the systematic review were solely from the articles reviewed and do not include information from patients, service users, caregivers, or members of the public.
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Affiliation(s)
- Jennifer J Lee
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Emma Jagasia
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Patty R Wilson
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Anastas TM, Stewart JC, Rand KL, Hirsh AT. Pain in People Experiencing Homelessness: A Scoping Review. Ann Behav Med 2023; 57:288-300. [PMID: 36745022 PMCID: PMC10094969 DOI: 10.1093/abm/kaac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prior work suggests that people experiencing homelessness (PEH) are at heightened risk for developing pain and have a uniquely burdensome pain experience. PURPOSE The aim of this scoping review was to map the current peer-reviewed, published literature on the pain experience of PEH. METHODS In accordance with the US Annual Homeless Assessment Report, we defined homelessness as lacking shelter or a fixed address within the last year. We conceptualized the pain experience via a modified version of the Social Communication Model of Pain, which considers patient, provider, and contextual factors. Published articles were identified with CINHAL, Embase, PubMed, PsycINFO, and Web of Science databases. RESULTS Sixty-nine studies met inclusion criteria. Studies revealed that PEH have high rates of pain and experience high levels of pain intensity and interference. Substantially fewer studies examined other factors relevant to the pain experience, such as self-management, treatment-seeking behaviors, and pain management within healthcare settings. Nonetheless, initial evidence suggests that pain is undermanaged in PEH. CONCLUSIONS Future research directions to understand pain and homelessness are discussed, including factors contributing to the under-management of pain. This scoping review may inform future work to develop interventions to address the specific pain care needs of PEH.
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Affiliation(s)
- Tracy M Anastas
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Jesse C Stewart
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Kevin L Rand
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Adam T Hirsh
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
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Bark P, Ramasawmy M, Hayward A, Luchenski S, Aldridge R, Burridge S, Banerjee A. Integrated approach to cardiovascular disease in people experiencing homelessness: a qualitative study. Open Heart 2023; 10:openhrt-2022-002235. [PMID: 37055174 PMCID: PMC10106063 DOI: 10.1136/openhrt-2022-002235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Homelessness is associated with an increased risk of cardiovascular disease (CVD), beyond impact of socioeconomic status. CVD is preventable and treatable, though barriers to interventions exist for people experiencing homelessness. Those with lived experience of homelessness and health professionals with relevant expertise can help to understand and address these barriers. OBJECTIVES To understand, and make recommendations to improve, CVD care in homeless populations through lived and professional expertise. METHOD Four focus groups were conducted in March-July 2019. Three groups included people currently or previously experiencing homelessness, each attended by a cardiologist (AB), a health services researcher (PB) and an 'expert by experience' (SB) who coordinated participants. One group included multidisciplinary health and social care professionals in and around London to explore solutions. PARTICIPANTS The three groups included 16 men and 9 women, aged 20-60 years, of whom 24 were homeless and currently living in hostels, and 1 rough sleeper. At least 14 discussed sleeping rough at some point. RESULTS Participants were aware of CVD risks and relevance of healthy habits but identified barriers to prevention and health access, starting with disorientation affecting planning and self-care, lack of facilities for food, hygiene and exercise, and experiences of discrimination. CONCLUSIONS CVD care for those experiencing homelessness should account for fundamental problems of the environment, be codesigned with service users and cover key principles: flexibility, public and staff education, integration of support and advocacy for health service rights.
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Affiliation(s)
- Pippa Bark
- Institute of Health Informatics, University College London, London, UK
- University College London Cancer Institute, London, UK
| | - Mel Ramasawmy
- Institute of Health Informatics, University College London, London, UK
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, London, UK
| | - Serena Luchenski
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Robert Aldridge
- Institute of Health Informatics, University College London, London, UK
| | | | - Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, London, UK
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11
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Arnos D, Acevedo A. Homelessness and Gender: Differences in Characteristics and Comorbidity of Substance Use Disorders at Admission to Services. Subst Use Misuse 2023; 58:27-35. [PMID: 36519365 DOI: 10.1080/10826084.2022.2136491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Substance use disorders and homelessness are two closely related behavioral health issues. This study examines associations between homelessness and severity of substance use disorder (SUD) characteristics (inclusive of alcohol and other legal and illegal drugs) and presence of mental health comorbidity among individuals entering treatment for SUD. We also examine differences in SUD and mental health comorbidity by gender within a sample of clients experiencing homelessness upon admission to treatment. Methods: Using the 2017 Treatment Episodes Data Set, we used logistic regression models to examine the association between homelessness and indicators of severity (e.g., frequency of use, route of transmission) and the presence of mental health conditions, and to examine the association between gender and these dependent variables among only individuals experiencing homelessness at treatment admission. Results: After controlling for covariates, homelessness is significantly associated with increased odds of cocaine and methamphetamine use compared to all other substances, higher frequency of use, younger age of first use, use of more substances, injection drug use, and co-occurring mental health conditions. Female gender is inversely associated with younger age at first use and highly associated with co-occurring mental health conditions among those experiencing homelessness at admission to treatment. Conclusions: Individuals experiencing homelessness enter substance use services with different characteristics of substance use disorders, different patterns of use, and with higher rates of mental health comorbidity. Within homeless admissions, women have significant differences in substance use and higher likelihood of mental health comorbidity than men. Future research should focus on the specific treatment needs of individuals experiencing homelessness, and how the combination of homelessness and gender affects barriers and challenges to treatment.
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Affiliation(s)
- Diane Arnos
- School of Public Health, University of California, Berkeley, California, USA
| | - Andrea Acevedo
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
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12
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Liu M, Pridham KF, Jenkinson J, Nisenbaum R, Richard L, Pedersen C, Brown R, Virani S, Ellerington F, Ranieri A, Dada O, To M, Fabreau G, McBrien K, Stergiopoulos V, Palepu A, Hwang S. Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial. BMJ Open 2022; 12:e065688. [PMID: 36517099 PMCID: PMC9756200 DOI: 10.1136/bmjopen-2022-065688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have not been rigorously evaluated. The Navigator Programme is a Critical Time Intervention case management programme that was developed to help homeless patients with their postdischarge needs and to link them with community-based health and social services. This randomised controlled trial examines the impact of the Navigator Programme on posthospital outcomes among adults experiencing homelessness. METHODS AND ANALYSIS This is a pragmatic randomised controlled trial testing the effectiveness of the Navigator Programme at an urban academic teaching hospital and an urban community teaching hospital in Toronto, Canada. Six hundred and forty adults experiencing homelessness who are admitted to the hospital will be randomised to receive support from a Homeless Outreach Counsellor for 90 days after hospital discharge or to usual care. The primary outcome is follow-up with a primary care provider (physician or nurse practitioner) within 14 days of hospital discharge. Secondary outcomes include postdischarge mortality or readmission, number of days in hospital, number of emergency department visits, self-reported care transition quality, and difficulties meeting subsistence needs. Quantitative outcomes are being collected over a 180-day period through linked patient-reported and administrative health data. A parallel mixed-methods process evaluation will be conducted to explore intervention context, implementation and mechanisms of impact. ETHICS AND DISSEMINATION Ethics approval was obtained from the Unity Health Toronto Research Ethics Board. Participants will be required to provide written informed consent. Results of the main trial and process evaluation will be reported in peer-reviewed journals and shared with hospital leadership, community partners and policy makers. TRIAL REGISTRATION NUMBER NCT04961762.
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Affiliation(s)
- Michael Liu
- Harvard Medical School, Boston, Massachusetts, USA
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jesse Jenkinson
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Lucie Richard
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rebecca Brown
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Sareeha Virani
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Fred Ellerington
- Division of General Internal Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alyssa Ranieri
- Division of General Internal Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Oluwagbenga Dada
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Matthew To
- Division of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Fabreau
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kerry McBrien
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen Hwang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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13
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Luchenski SA, Dawes J, Aldridge RW, Stevenson F, Tariq S, Hewett N, Hayward AC. Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review. EClinicalMedicine 2022; 54:101657. [PMID: 36311895 PMCID: PMC9597099 DOI: 10.1016/j.eclinm.2022.101657] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness. METHODS We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines. FINDINGS Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions. INTERPRETATION Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions. FUNDING SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).
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Affiliation(s)
- Serena A. Luchenski
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
- Corresponding author.
| | - Joanna Dawes
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
| | - Robert W. Aldridge
- Centre for Public Health Data Science, Institute for Health Informatics, University College London, 255 Euston Road, London NW1 2DA, United Kingdom
| | - Fiona Stevenson
- Department of Primary Care and Population Health, Institute of Epidemiology and Healthcare, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Shema Tariq
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, Mortimer Market Centre, off Capper Street, London WC1E 6JB, United Kingdom
| | - Nigel Hewett
- Pathway, 4th Floor, East, 250 Euston Rd, London NW1 2PG, United Kingdom
| | - Andrew C. Hayward
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
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14
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Flike K, Hayman LL, Byrne T, Song Q, Aronowitz T. The impact of patient-centred care on the relationship between access to care and subjective health outcomes amongst people experiencing homelessness: A mediation analysis. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5755-e5764. [PMID: 36093584 DOI: 10.1111/hsc.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 06/15/2023]
Abstract
People experiencing homelessness (PEH) have stated that impersonal care and feelings of discrimination are barriers to accessing healthcare which is associated with poor health outcomes amongst PEH. This study examined whether patient-centred care (PCC) mediates the relationship between access to care and subjective health outcomes. Using the 2014-15 Healthcare Center Patient Survey, we identified 1873 homeless and vulnerably housed adults. Items related to the delay or inability to receive primary or mental healthcare, PCC provided by healthcare providers, general health status, and the Kessler-6 psychological distress scale were selected. Ordinary least squares analyses were used to perform mediation analysis. We found that both access to primary care and access to mental healthcare were positively associated with physical health status (β = 0.492, p < 0.001; β = 0.311, p < 0.001) and negatively associated with psychological distress (β = -2.53, p < 0.001; β = -1.85, p < 0.001). PCC partially mediated all associations, but the mediation was stronger in the relationships between access to primary care and health outcomes (ab = 0.25, 95% CI [0.002, 0.052]; ab = -0.21, 95% CI [-0.37, -0.07]) compared to mental healthcare (ab = 0.02, 95% CI [0.01, 0.04]; ab = -0.14, 95% CI [-0.25, -0.06]). The results of this study indicated access to primary and mental healthcare is important in the patient-centred health outcomes of PEH. Additionally, the partial mediation of PCC in these relationships indicated that participants' perception of collaborative, trustworthy, respectful care from healthcare providers impacted the relationship between access to healthcare and health outcomes.
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Affiliation(s)
- Kimberlee Flike
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Healthcare System, Bedford, Massachusetts, USA
| | - Laura L Hayman
- Robert and Donna Manning College Nursing & Health Sciences, University of Massachusetts, Boston, Massachusetts, USA
| | - Thomas Byrne
- School of Social Work, Boston University, Boston, Massachusetts, USA
| | - Qian Song
- McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, Massachusetts, USA
| | - Teri Aronowitz
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, USA
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15
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Babulal GM, Rani R, Adkins-Jackson P, Pearson AC, Williams MM. Associations between Homelessness and Alzheimer's Disease and Related Dementia: A Systematic Review. J Appl Gerontol 2022; 41:2404-2413. [PMID: 35750476 PMCID: PMC10018777 DOI: 10.1177/07334648221109747] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The homeless population in the United States is rapidly aging, with a parallel increase in Alzheimer's disease and related dementia (ADRD). During an evolving pandemic that jeopardizes employment and housing, assessing the relationship between ADRD and homelessness is critical since the latter is potentially intervenable. The objective of this study is to review the literature and determine whether there is an association between homelessness and dementia risk. A systematic review of existing studies was conducted through PubMED, SCOPUS, and EMBASE among others. Of the 228 results found, nine met inclusion criteria. Homeless studies mainly centered on veteran populations (n = 6/9). There is a complex relationship suggesting homelessness as a risk for and consequence of ADRD but also co-occurrence with psychiatric disorders, substance abuse, and traumatic injuries. Future studies should employ enumeration surveys with modular longitudinal tracking and measure social determinants of health, discrimination, chronic stress, and mood disorders.
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Affiliation(s)
- Ganesh M. Babulal
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
- Institute of Public Health, Washington University in St. Louis, St. Louis, MO, USA
- Department of Psychology, Faculty of Humanities, University of Johannesburg, South Africa
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rohan Rani
- Department of Molecular and Cellular Biology, University of California Santa Barbara, Santa Barbara, CA, USA
| | | | - Adam C. Pearson
- Peter & Paul Community Services, St. Louis, MO, USA
- Program in Occupational Therapy, Washington University in St. Louis, St. Louis, MO, USA
| | - Monique M. Williams
- Program in Occupational Therapy, Washington University in St. Louis, St. Louis, MO, USA
- New Horizons PACE, St. Louis, MO, USA
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16
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Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol. Pilot Feasibility Stud 2022; 8:211. [PMID: 36114586 PMCID: PMC9479401 DOI: 10.1186/s40814-022-01165-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/25/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.
Method
We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).
Discussion
Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.
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Zufferey Cz C, Skovdal Ms M, Gjødsbøl Img IM, Jervelund Ssj SS. Caring for people experiencing homelessness in times of crisis: Realities of essential service providers during the COVID-19 pandemic in Copenhagen, Denmark. INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION : IJDRR 2022; 79:103157. [PMID: 35845103 PMCID: PMC9273523 DOI: 10.1016/j.ijdrr.2022.103157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The COVID-19 pandemic shed light on rooted social inequalities and on housing as a crucial social determinant of health. Little is known on current practices and new opportunities to support people experiencing homelessness in a situation of a global health crisis. This study explores frontline workers' experiences of providing essential services to people experiencing homelessness in Copenhagen, Denmark, during the first COVID-19 lockdown, and highlights best practices of care in future crises. METHODS Semi-structured interviews were conducted in August-September 2020 with nine service providers working in six organizations offering essential services to people experiencing homelessness during the spring 2020 lockdown in Copenhagen. The data analysis, following inductive coding, drew upon the concept of disaster resilience. RESULTS Several initiatives were undertaken by the municipality and local organizations to ensure the continuation and adaptation of essential services to people experiencing homelessness during the COVID-19 crisis. These included collaborations with and financial support from businesses, the municipality, and other service providers; a mobile test unit, temporary shelters, and isolation sites; and an increased availability of opioid substitution treatment. Several improvements are to be made, particularly regarding sustainability and long-term benefits of the initiatives, facility-level risk preparedness, universal access to essential services for undocumented migrants, as well as collaboration between service providers. CONCLUSIONS The lockdown offered the opportunity to experiment with innovative ways of working, of which many had a protective effect on people experiencing homelessness. This knowledge can be used to improve services and reduce the long-term vulnerability of people experiencing homelessness.
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Affiliation(s)
- Chloé Zufferey Cz
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Denmark
| | - Morten Skovdal Ms
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Denmark
| | | | - Signe Smith Jervelund Ssj
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Denmark
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18
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Prevalence and factors associated with hospitalisation for bacterial skin infections among people who inject drugs: The ETHOS Engage Study. Drug Alcohol Depend 2022; 237:109543. [PMID: 35772249 DOI: 10.1016/j.drugalcdep.2022.109543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Injecting-related skin and soft tissue infections (SSTIs) are a preventable cause of inpatient hospitalisation among people who inject drugs (PWID). This study aimed to determine the prevalence of hospitalisation for SSTIs among PWID, and identify similarities and differences in factors associated with hospitalisation for SSTIs versus non-bacterial harms related to injecting drug use. METHODS We performed cross-sectional analyses of baseline data from an observational cohort study of PWID attending drug treatment clinics and needle and syringe programs in Australia. Logistic regression models were used to identify factors associated with self-reported hospitalisation for (1) SSTIs (abscess and/or cellulitis), and (2) non-bacterial harms related to injecting drug use (e.g., non-fatal overdose; hereafter referred to as non-bacterial harms), both together and separately. RESULTS 1851 participants who injected drugs in the previous six months were enrolled (67% male; 85% injected in the past month; 42% receiving opioid agonist treatment [OAT]). In the previous year, 40% (n = 737) had been hospitalised for drug-related causes: 20% (n = 377) and 29% (n = 528) of participants were admitted to hospital for an SSTI and non-bacterial harm, respectively. Participants who were female (adjusted odds ratio [aOR]: 1.53, 95% CI: 1.19-1.97) or homeless (aOR: 1.59, 95% CI: 1.16-2.19) were more likely to be hospitalised for an SSTI, but not a non-bacterial harm. Both types of hospitalisation were more likely among people recently released from prison. CONCLUSIONS Hospitalisation for SSTIs is common among PWID. Community-based interventions to prevent SSTIs and subsequent hospitalisation among PWID will require targeting of at-risk groups, including women, people experiencing homelessness, and incarcerated people upon prison release.
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19
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Fornaro M, Dragioti E, De Prisco M, Billeci M, Mondin AM, Calati R, Smith L, Hatcher S, Kaluzienski M, Fiedorowicz JG, Solmi M, de Bartolomeis A, Carvalho AF. Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials. BMC Med 2022; 20:224. [PMID: 35818057 PMCID: PMC9273695 DOI: 10.1186/s12916-022-02423-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population. METHODS Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted. RESULTS Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant. CONCLUSION While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.
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Affiliation(s)
- Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Michele De Prisco
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Martina Billeci
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Anna Maria Mondin
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Raffaella Calati
- Department of Psychology, University of Milan-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, Italy
- Department of Adult Psychiatry, Nimes University Hospital, 4 Rue du Professeur Robert Debré, 30029 Nimes, France
| | - Lee Smith
- Cambridge Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Simon Hatcher
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Mark Kaluzienski
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
| | - Jess G. Fiedorowicz
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, London, UK
- Faculty of Environmental and Life Sciences, Center for Innovation in Mental Health, School of Psychology, University of Southampton, Southampton, UK
| | - Andrea de Bartolomeis
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
- UNESCO staff, Chair - “Education for Health and Sustainable Development”, University of Naples, Federico II Naples, Naples, Italy
| | - André F. Carvalho
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
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20
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Berner L, Meehan A, Kenkel J, Montgomery M, Fields V, Henry A, Boyer A, Mosites E, Vickery KD. Clinic- and Community-Based SARS-CoV-2 Testing Among People Experiencing Homelessness in the United States, March–November 2020. Public Health Rep 2022; 137:764-773. [PMID: 35403502 PMCID: PMC9066227 DOI: 10.1177/00333549221086514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: SARS-CoV-2 testing is a critical component of preventing the spread of COVID-19. In the United States, people experiencing homelessness (PEH) have accessed testing at health clinics, such as those provided through Health Care for the Homeless (HCH) clinics or through community-based testing events at homeless service sites or encampments. We describe data on SARS-CoV-2 testing among PEH in US clinic- and community-based settings from March through November 2020. Methods: We conducted a descriptive analysis of data from HCH clinics and community testing events. We used a standardized survey to request data from HCH clinics. We developed and made publicly available an online data entry portal to collect data from community-based organizations that provided testing for PEH. We assessed positivity rates across clinics and community service sites serving PEH and used generalized linear mixed models to account for clustering. Results: Thirty-seven HCH clinics reported providing 280 410 tests; 3.2% (n = 8880) had positive results (range, 1.6%-4.9%). By race, positivity rates were highest among people who identified as >1 race (11.6%; P < .001). During the reporting period, 22 states reported 287 community testing events and 14 116 tests; 7.1% (n = 1004) had positive results. Among facility types, day shelters (380 of 2697; 14.1%) and inpatient drug/alcohol rehabilitation facilities (32 of 251; 12.7%) reported the highest positivity rates. Conclusions: While HCH clinic data provided results for a larger number of patients, community-based testing data showed higher positivity rates. Clinic data demonstrated racial disparities in positivity. Community-based testing data provided information about SARS-CoV-2 transmission settings. Although these data provide information about testing, standard surveillance systems are needed to better understand the incidence of disease among PEH.
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Affiliation(s)
- Lauryn Berner
- National Health Care for the Homeless Council, Nashville, TN, USA
| | - Ashley Meehan
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joseph Kenkel
- National Health Care for the Homeless Council, Nashville, TN, USA
| | - Martha Montgomery
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria Fields
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ankita Henry
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alaina Boyer
- National Health Care for the Homeless Council, Nashville, TN, USA
| | - Emily Mosites
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
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21
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Győrffy Z, Békási S, Döbrössy B, Bognár VK, Radó N, Morva E, Zsigri S, Tari P, Girasek E. Exploratory attitude survey of homeless persons regarding telecare services in shelters providing mid- and long-term accommodation: The importance of trust. PLoS One 2022; 17:e0261145. [PMID: 34990458 PMCID: PMC8735598 DOI: 10.1371/journal.pone.0261145] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 11/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the expansion of digital health, it is imperative to consider intervention techniques in order not to be the cause of even more social health inequalities in underserved populations struggling with chronic diseases. Telemedicine solutions for homeless persons might compensate for shortcomings in access to valuable health services in different settings. The main aim of our research was to examine the attitudes and openness of homeless persons regarding telecare on a Hungarian sample. METHODS Quantitative survey among homeless people (n = 98) was completed in 4 shelters providing mid- and long-term accommodation in Budapest, Hungary. Attitudes regarding healthcare service accessibility and telecare were measured by a self-developed questionnaire of the research team. Telecare attitude comparison was made with data of a Hungarian weighted reference group of non-homeless persons recruited from 2 primary care units (n = 110). RESULTS A significant fraction of homeless people with mid- or long-term residency in homeless shelters did not oppose the use of telecare via live online video consultation and there was no difference compared to the national reference group (averages of 3.09 vs. 3.15, respectively). Results of the homeless group indicate that those more satisfied with healthcare services, in general, manifest more openness to telecare. It is clearly demonstrated by the multivariate analysis that those participants in the homeless group who had problems getting health care in the last year definitely preferred in-person doctor-patient consultations. CONCLUSION Digital health technologies offer a potentially important new pathway for the prevention and treatment of chronic conditions among homeless persons. Based on the attitudes towards telecare, initiating an on-site telecare program for mid- and long-term residents of homeless shelters might enable better care continuity. Our results draw attention to the key factors including building trust in the implementation of such programs among underserved and other vulnerable patient groups.
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Affiliation(s)
- Zsuzsa Győrffy
- Faculty of Medicine, Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
| | - Sándor Békási
- Health Center, Hungarian Charity Service of the Order of Malta, Budapest, Hungary
- Telemedicine Workgroup, FitPuli Kft., Győr, Hungary
| | - Bence Döbrössy
- Faculty of Medicine, Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
| | - Virág Katalin Bognár
- Faculty of Medicine, Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
| | - Nóra Radó
- Faculty of Medicine, Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
| | - Emília Morva
- Regional Directorate, Hungarian Charity Service of the Order of Malta, Budapest, Hungary
| | | | | | - Edmond Girasek
- Faculty of Medicine, Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
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22
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Montgomery MP, Hong K, Clarke KEN, Williams S, Fukunaga R, Fields VL, Park J, Schieber LZ, Kompaniyets L, Ray CM, Lambert LA, D’Inverno AS, Ray TK, Jeffers A, Mosites E. Hospitalizations for COVID-19 Among US People Experiencing Incarceration or Homelessness. JAMA Netw Open 2022; 5:e2143407. [PMID: 35024835 PMCID: PMC8759002 DOI: 10.1001/jamanetworkopen.2021.43407] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE People experiencing incarceration (PEI) and people experiencing homelessness (PEH) have an increased risk of COVID-19 exposure from congregate living, but data on their hospitalization course compared with that of the general population are limited. OBJECTIVE To compare COVID-19 hospitalizations for PEI and PEH with hospitalizations among the general population. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used data from the Premier Healthcare Database on 3415 PEI and 9434 PEH who were evaluated in the emergency department or were hospitalized in more than 800 US hospitals for COVID-19 from April 1, 2020, to June 30, 2021. EXPOSURES Incarceration or homelessness. MAIN OUTCOMES AND MEASURES Hospitalization proportions were calculated. and outcomes (intensive care unit admission, invasive mechanical ventilation [IMV], mortality, length of stay, and readmissions) among PEI and PEH were compared with outcomes for all patients with COVID-19 (not PEI or PEH). Multivariable regression was used to adjust for potential confounders. RESULTS In total, 3415 PEI (2952 men [86.4%]; mean [SD] age, 50.8 [15.7] years) and 9434 PEH (6776 men [71.8%]; mean [SD] age, 50.1 [14.5] years) were evaluated in the emergency department for COVID-19 and were hospitalized more often (2170 of 3415 [63.5%] PEI; 6088 of 9434 [64.5%] PEH) than the general population (624 470 of 1 257 250 [49.7%]) (P < .001). Both PEI and PEH hospitalized for COVID-19 were more likely to be younger, male, and non-Hispanic Black than the general population. Hospitalized PEI had a higher frequency of IMV (410 [18.9%]; adjusted risk ratio [aRR], 1.16; 95% CI, 1.04-1.30) and mortality (308 [14.2%]; aRR, 1.28; 95% CI, 1.11-1.47) than the general population (IMV, 88 897 [14.2%]; mortality, 84 725 [13.6%]). Hospitalized PEH had a lower frequency of IMV (606 [10.0%]; aRR, 0.64; 95% CI, 0.58-0.70) and mortality (330 [5.4%]; aRR, 0.53; 95% CI, 0.47-0.59) than the general population. Both PEI and PEH had longer mean (SD) lengths of stay (PEI, 9 [10] days; PEH, 11 [26] days) and a higher frequency of readmission (PEI, 128 [5.9%]; PEH, 519 [8.5%]) than the general population (mean [SD] length of stay, 8 [10] days; readmission, 28 493 [4.6%]). CONCLUSIONS AND RELEVANCE In this cross-sectional study, a higher frequency of COVID-19 hospitalizations for PEI and PEH underscored the importance of adhering to recommended prevention measures. Expanding medical respite may reduce hospitalizations in these disproportionately affected populations.
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Affiliation(s)
- Martha P. Montgomery
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kai Hong
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kristie E. N. Clarke
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Samantha Williams
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rena Fukunaga
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Victoria L. Fields
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joohyun Park
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyna Z. Schieber
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyudmyla Kompaniyets
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Colleen M. Ray
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauren A. Lambert
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ashley S. D’Inverno
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tapas K. Ray
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexiss Jeffers
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily Mosites
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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D'Souza MS, O'Mahony J, Achoba A. Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach. J Prim Care Community Health 2022; 13:21501319211065247. [PMID: 35090358 PMCID: PMC8801709 DOI: 10.1177/21501319211065247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: People experiencing homelessness are faced with complex challenges and are at high risk of illness due to inequities and disparities in access to health care services. Objective: To explore the health and foot care problems related to people experiencing homelessness in British Columbia. Methods: A community participatory research approach was used with a sample of 65 people experiencing homelessness. Data were collected using a survey questionnaire and face-to-face semistructured interviews. Results: Thematic findings shows risk of foot injuries, lack of foot care resources, and absence of family support. Barriers to equitable access to services for most participants experiencing homelessness were lack of housing (76.92%), inability to work (72.31%), and inability to afford the cost of living on their own (63.08%). Conclusions: There is a pressing need for early screening and detection by health care professionals and enhanced foot care services to reduce foot problems and improve foot care wellness of homeless people. Addressing foot-related care are necessary steps in promoting health, preventing illness, and improving access to health services among people experiencing homelessness.
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Affiliation(s)
| | | | - Alfred Achoba
- Executive Director, Canadian Mental Health Association, Kamloops
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24
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Corker E, Lorencatto F, Anderson N, Gobin M, Scott S, Michie S, Angel G. Acceptability and facilitators of and barriers to point-of-care HIV testing in a homeless-focused service in Gloucestershire: a qualitative evaluation. HIV Med 2021; 23:237-248. [PMID: 34693615 DOI: 10.1111/hiv.13187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Late HIV diagnosis increases the risks of onward transmission, morbidity and mortality. Rapid point-of-care testing (POCT) reaches people who have never been tested and people living with HIV who are undiagnosed. This study explored the acceptability and feasibility of HIV POCT from the perspectives of service providers and users. METHODS A pilot study introduced HIV POCT to one service in Gloucestershire, England. Eleven semi-structured interviews with service users and a focus group with three service providers were conducted. The Theoretical Framework of Acceptability and the Theoretical Domains Framework were used to design the topic guide and analysis. RESULTS Acceptability of HIV POCT was high. Seven facilitators were identified (e.g. understanding the test purpose and process), alongside two potential barriers, one relevant to service providers and users (anxiety) and the other to service users (stigma). CONCLUSIONS To maximize the benefits of implementation of HIV POCT, health care providers require appropriate training and supervision to offer and administer POCT.
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Affiliation(s)
- Elizabeth Corker
- Department of Clinical, Educational, and Health Psychology, Centre for Behaviour Change, University College London, London, UK
| | - Fabiana Lorencatto
- Department of Clinical, Educational, and Health Psychology, Centre for Behaviour Change, University College London, London, UK
| | - Niall Anderson
- Department of Clinical, Educational, and Health Psychology, Centre for Behaviour Change, University College London, London, UK
| | | | - Sarah Scott
- Gloucestershire County Council, Gloucester, UK
| | - Susan Michie
- Department of Clinical, Educational, and Health Psychology, Centre for Behaviour Change, University College London, London, UK
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25
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Thurman W, Moczygemba LR, Baffoe JO. "Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness. Res Social Adm Pharm 2021; 18:3149-3157. [PMID: 34479800 DOI: 10.1016/j.sapharm.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND People experiencing homelessness (PEH) live with a high burden of chronic illness, functional and cognitive impairments, and serious mental illness. Many PEH are prescribed complex medication regimens to manage symptoms and improve health and functioning. However, medication use within the context of homelessness is complicated, and adherence is often suboptimal. OBJECTIVE To document medication use within the context of homelessness and explore experiences of medication use among people experiencing homelessness (PEH). METHODS This study used mixed methods including photo-elicitation interviews. Participants were given a digital camera and asked to take pictures of people, places, things, and situations that represented every day medication use. Participants were also asked to write down reasons for taking the pictures. After two weeks, participants returned the camera and notes. At a subsequent interview, the photographs and notes were reviewed and discussed. Demographic and health-related information was also collected for each participant. An interpretive description approach was used for qualitative data analysis. Quantitative data were analyzed using descriptive statistics in order to describe the sample. RESULTS Seven PEH completed this study. Mean age was 45 years (SD = 11.3) and length of homelessness was 6.1 years (SD = 11.3). All reported multiple chronic conditions (≥2) and reported taking 6.6 (SD = 2.6) medications. Participants reported medication adherence barriers with mean score of 37 (SD = 5.5) on the ASK-12, a 12-item scale with a range of 12-60 (higher scores indicate more barriers). Qualitative analysis identified four categories: medication-related burdens, medication-related beliefs, connectedness, and stigmatizing encounters. CONCLUSIONS Medication use among PEH is complex and cannot be considered separately from daily life or from struggles to meet basic needs. Multi-level interventions are needed to optimize medication use among PEH, and healthcare professionals including community pharmacists should reinforce beliefs that medication-related benefits outweigh the burdens and then tailor services to the context of homelessness.
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Affiliation(s)
- Whitney Thurman
- College of Pharmacy, Health Outcomes Division, The University of Texas at Austin, 2900 University Ave. Austin, TX, 78712, USA; School of Nursing, The University of Texas at Austin, 1710 Red River St. Austin, TX, 78701, USA.
| | - Leticia R Moczygemba
- College of Pharmacy, Health Outcomes Division, The University of Texas at Austin, 2900 University Ave. Austin, TX, 78712, USA
| | - James O Baffoe
- College of Pharmacy, Health Outcomes Division, The University of Texas at Austin, 2900 University Ave. Austin, TX, 78712, USA
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26
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Ra CK, Hébert ET, Alexander A, Kendzor DE, Suchting R, Businelle MS. Unsheltered homeless and unstably housed adults have higher levels of stress and more health risk factors than sheltered homeless adults. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2021; 32:42-50. [PMID: 37346936 PMCID: PMC10281693 DOI: 10.1080/10530789.2021.1961990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/08/2021] [Accepted: 07/18/2021] [Indexed: 06/23/2023]
Abstract
In the United States, approximately 580,000 individuals were homeless on a single night in 2020. Homelessness can be categorized into three subgroups: sheltered homeless, unsheltered homeless, and unstably housed. Few studies have examined the relations between homelessness subtypes, shelter service utilization, levels of stress experienced, and health risk factors. This study aimed to empirically examine whether shelter status the previous night was related to current stress, recent utilization of shelter-based mental health services, and current health risk factors. Data were collected at multiple homeless shelters in 2016 in the Oklahoma City area (N=575). All participants completed assessments of demographic characteristics, including age, sex, race, marital status, years of education, and incarceration history and victimization. Multiple linear and logistic regression analyses were conducted to examine relations between homelessness subgroups and outcomes (shelter-based service utilization, health risk factors, and stressors). Results indicated that the sheltered group was younger and more likely to be White than the unsheltered group, had higher levels of education, and reported more lifetime months in jail than the unstably housed group. In addition, unsheltered homeless and unstably housed adults used fewer shelter-based health services, exhibited more health risk factors, experienced greater levels of stress, and had higher levels of food insecurity than sheltered homeless adults. Homeless adults who reside at shelters benefit most from available shelter services. The development of policies and programs targeted toward increasing sheltering options for unsheltered and unstably housed adults is needed.
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Affiliation(s)
- Chaelin K. Ra
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
| | - Emily T. Hébert
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Adam Alexander
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Robert Suchting
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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27
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Dawkins B, Renwick C, Ensor T, Shinkins B, Jayne D, Meads D. What factors affect patients' ability to access healthcare? An overview of systematic reviews. Trop Med Int Health 2021; 26:1177-1188. [PMID: 34219346 DOI: 10.1111/tmi.13651] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This overview aims to synthesise global evidence on factors affecting healthcare access, and variations across low- and middle-income countries (LMICs) vs. high-income countries (HICs); to develop understanding of where barriers to healthcare access lie, and in what context, to inform tailored policies aimed at improving access to healthcare for all who need it. METHODS An overview of systematic reviews guided by a published protocol was conducted. Medline, Embase, Global Health and Cochrane Systematic Reviews databases were searched for published articles. Additional searches were conducted on the Gates Foundation, WHO and World Bank websites. Study characteristics and findings (barriers and facilitators to healthcare access) were documented and summarised. The methodological quality of included studies was assessed using an adapted version of the AMSTAR 2 tool. RESULTS Fifty-eight articles were included, 23 presenting findings from LMICs and 35 presenting findings from HICs. While many barriers to healthcare access occur in HICs as well as LMICs, the way they are experienced is quite different. In HICs, there is a much greater emphasis on patient experience; as compared to the physical absence of care in LMICs. CONCLUSIONS As countries move towards universal healthcare access, evaluation methods that account for health system and wider cultural factors that impact capacity to provide care, healthcare finance systems and the socio-cultural environment of the setting are required. Consequently, methods employed in HICs may not be appropriate in LMICs due to the stark differences in these areas.
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Affiliation(s)
- Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Tim Ensor
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Jayne
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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28
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Gilmer C, Buccieri K. Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain. J Prim Care Community Health 2021; 11:2150132720910289. [PMID: 32133906 PMCID: PMC7059226 DOI: 10.1177/2150132720910289] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.
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Affiliation(s)
| | - Kristy Buccieri
- Trent University, Peterborough, Ontario,
Canada
- Kristy Buccieri, Department of Sociology,
Trent University, 1600 West Bank Drive, Peterborough, Ontario K9L 0G2, Canada.
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29
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Louie AD, Nwaiwu CA, Rozenberg J, Banerjee D, Lee GJ, Senthoor D, Miner TJ. Providing Appropriate Pancreatic Cancer Care for People Experiencing Homelessness: A Surgical Perspective. Am Soc Clin Oncol Educ Book 2021; 41:1-9. [PMID: 33929879 DOI: 10.1200/edbk_100027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
People experiencing homelessness are particularly vulnerable when diagnosed with pancreatic cancer. Patients with lower socioeconomic status have worse outcomes from pancreatic cancer as the result of disparities in access to treatment and barriers to navigation of the health care system. Patients with lower socioeconomic status, or who are vulnerably housed, are less likely to receive surgical treatment even when it is recommended by National Comprehensive Cancer Network guidelines. This disparity in access to surgical care explains much of the gap in pancreatic cancer outcomes. There are many factors that contribute to this disparity in surgical management of pancreatic cancer in people experiencing homelessness. These include a lack of reliable transportation, feeling unwelcome in the medical setting, a lack of primary care and health insurance, and implicit biases of health care providers, including racial bias. Solutions that focus on rectifying these problems include utilizing patient navigators, addressing implicit biases of all health care providers and staff, creating an environment that caters to the needs of patients experiencing homelessness, and improving their access to insurance and regional support networks. Implementing these potential solutions all the way from the individual provider to national safety nets could improve outcomes for patients with pancreatic cancer who are experiencing homelessness.
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Affiliation(s)
- Anna D Louie
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
| | - Chibueze A Nwaiwu
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Supporting Underrepresented Research to Generate Equity (SURGE) Lab Collaborators, Warren Alpert Medical School of Brown University, Providence, RI
| | - Julia Rozenberg
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Debolina Banerjee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Gillian J Lee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Dewahar Senthoor
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Thomas J Miner
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
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30
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Montgomery MP, Paulin HN, Morris A, Cotton A, Speers A, Boyd AT, Buff AM, Mathews D, Wells A, Marchman C, Gaffga N, Bamrah Morris S, Cavanaugh SS. Establishment of Isolation and Noncongregate Hotels During COVID-19 and Symptom Evolution Among People Experiencing Homelessness-Atlanta, Georgia, 2020. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:285-294. [PMID: 33762544 PMCID: PMC10878749 DOI: 10.1097/phh.0000000000001349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT Local agencies across the United States have identified public health isolation sites for individuals with coronavirus disease 2019 (COVID-19) who are not able to isolate in residence. PROGRAM We describe logistics of establishing and operating isolation and noncongregate hotels for COVID-19 mitigation and use the isolation hotel as an opportunity to understand COVID-19 symptom evolution among people experiencing homelessness (PEH). IMPLEMENTATION Multiple agencies in Atlanta, Georgia, established an isolation hotel for PEH with COVID-19 and noncongregate hotel for PEH without COVID-19 but at risk of severe illness. PEH were referred to the isolation hotel through proactive, community-based testing and hospital-based testing. Daily symptoms were recorded prospectively. Disposition location was recorded for all clients. EVALUATION During April 10 to September 1, 2020, 181 isolation hotel clients (77 community referrals; 104 hospital referrals) were admitted a median 3 days after testing. Overall, 32% of community referrals and 7% of hospital referrals became symptomatic after testing positive; 83% of isolation hotel clients reported symptoms at some point; 93% completed isolation. Among 302 noncongregate hotel clients, median stay was 18 weeks; 61% were discharged to permanent housing or had a permanent housing discharge plan. DISCUSSION Overall, a high proportion of PEH completed isolation at the hotel, suggesting a high level of acceptability. Many PEH with COVID-19 diagnosed in the community developed symptoms after testing, indicating that proactive, community-based testing can facilitate early isolation. Noncongregate hotels can be a useful COVID-19 community mitigation strategy by bridging PEH at risk of severe illness to permanent housing.
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Affiliation(s)
- Martha P Montgomery
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Montgomery, Paulin, Boyd, Buff, Gaffga, Bamrah Morris, and Cavanaugh); Partners for HOME, Atlanta, Georgia (Mr Morris and Ms Marchman); Fulton County Board of Health, Atlanta, Georgia (Ms Cotton); Georgia Department of Public Health, Atlanta, Georgia (Ms Speers); Darlene Mathews, Incorporated, Atlanta, Georgia (Ms Mathews); and Mercy Care, Atlanta, Georgia (Ms Wells)
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Doran E, Barron E, Healy L, O'Connor L, Synnott C, Ní Cheallaigh C, Doherty C. Improving access to epilepsy care for homeless patients in the Dublin Inner City: a collaborative quality improvement project joining hospital and community care. BMJ Open Qual 2021; 10:bmjoq-2021-001367. [PMID: 33926992 PMCID: PMC8094364 DOI: 10.1136/bmjoq-2021-001367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/04/2021] [Accepted: 04/17/2021] [Indexed: 11/10/2022] Open
Abstract
Homelessness is associated with significant psychosocial and health disparities. The rate of epilepsy among this cohort is eight times greater than that in the settled population, and the associated morbidity is higher due to lack of integrated care, difficulties with treatment adherence, substance abuse and poor social circumstances. There is a high rate of seizure-related death in homeless patients. Seizures are one of the most common neurological cause for emergency department presentation among this population. The aim of this quality improvement project was to use a multistakeholder co-production approach to design a new pathway of care for homeless patients with epilepsy to improve access to specialist epilepsy care and to strengthen the links between hospital and community teams who manage this population. After several years of observation, stakeholder engagement and numerous tests of change, we have created a new care pathway and developed bespoke tools for primary care providers and for physicians working in the emergency department to enable them to assess and manage patients as they present, as well as provide access to remote epilepsy specialist support.
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Affiliation(s)
- Elisabeth Doran
- Neurology, Saint James's Hospital, Dublin, Ireland .,Neurologie, Sankt Georg Hospital Group, Leipzig, Germany
| | - Enda Barron
- Primay Care, Safety Net Primary Care, Dublin, Ireland
| | - Laura Healy
- Clinical Nutrition, Saint James's Hospital, Dublin, Ireland
| | | | - Cara Synnott
- Neurology, Saint James's Hospital, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- Inclusion Health, Saint James's Hospital, Dublin, Ireland.,Clinincal Medicine, Trinity College Dublin, Dublin, Ireland
| | - Colin Doherty
- Neurology, Saint James's Hospital, Dublin, Ireland.,Neurology, TCD, Dublin, Ireland
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Kaltsidis G, Grenier G, Cao Z, L'Espérance N, Fleury MJ. Typology of changes in quality of life over 12 months among currently or formerly homeless individuals using different housing services in Quebec, Canada. Health Qual Life Outcomes 2021; 19:128. [PMID: 33882927 PMCID: PMC8061013 DOI: 10.1186/s12955-021-01768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background In health and social service evaluations, including research on homelessness, quality of Life (QOL) is often used as a key indicator of well-being among service users. However, no typology has been developed on changes in QOL over a 12-month period for a heterogenous sample of homeless individuals. Methods Cluster analysis was employed to identify a typology of change in QOL for 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) and permanent housing (PH) services in Quebec (Canada). Participant interviews were conducted at baseline and 12 months later. An adapted Gelberg–Andersen Model helped organize QOL-related sociodemographic, clinical, and service use variables into predisposing, needs, and enabling factors, respectively. Comparison analyses were performed to determine group differences. Results Four groups emerged from the analyses: (1) young women in stable-PH or improved housing status with moderately high needs and specialized ambulatory care service use, with improved QOL over 12 months; (2) middle-age to older men with stable housing status, few needs and low acute care service use, with most improvement in QOL over 12 months; (3) older individuals residing in stable-PH or improved housing status with very high needs and reduced QOL over 12 months; and (4) men in stable-TH or worse housing status, with high substance use disorder, using few specialized ambulatory care services and showing decline in QOL over 12 months. Conclusions Findings suggest that positive change in QOL over 12 months was mainly associated with fewer needs, and stability in housing status more than housing improvement. Specific recommendations, such as assertive community treatment and harm reduction programs, should be prioritized for individuals with high needs or poor housing status, and among those experiencing difficulties related to QOL, whereas individuals with more favourable profiles could be encouraged to maintain stable housing and use services proportional to their needs.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux, Trois-Rivières, Quebec, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
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33
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Lonnie E, Pooja S, Allison G, Reuben K, David A, Juddy W, Edith A, Paula B. Exploring patient-provider interactions and the health system's responsiveness to street-connected children and youth in Kenya: a qualitative study. BMC Health Serv Res 2021; 21:363. [PMID: 33874934 PMCID: PMC8056657 DOI: 10.1186/s12913-021-06376-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/12/2021] [Indexed: 12/30/2022] Open
Abstract
Background In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY’s and healthcare provider’s reflections on their interactions with each other. Methods This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY’s experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness. Results Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY’s interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers’ adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness. Conclusions This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY’s experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06376-6.
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Affiliation(s)
- Embleton Lonnie
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada
| | - Shah Pooja
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK.,Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Gayapersad Allison
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Kiptui Reuben
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Ayuku David
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya.,Department of Behavioural Science, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Wachira Juddy
- Department of Behavioural Science, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Apondi Edith
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Braitstein Paula
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. .,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada. .,Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya. .,Moi University, College of Health Sciences, School of Medicine, P.O. Box 4606-30100, Eldoret, Kenya.
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Raad JH, Tarlov E, Kho AN, French DD. Health Care Utilization Among Homeless Veterans in Chicago. Mil Med 2021; 185:e335-e339. [PMID: 31714995 DOI: 10.1093/milmed/usz264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The U.S. Department of Veterans Affairs (VA), the single largest health care system in the United States, provides comprehensive medical and behavioral health services to more than 9 million Veterans. The size and scope of the VA's system of care allow health care providers, policymakers, and community stakeholders to conduct detailed analyses of health care utilization among Veterans; however, these analyses do not include health care encounters that occur outside VA. Although many Veterans obtain care in non-VA settings, understanding health care utilization among vulnerable populations of Veterans, including those who are homeless or at risk of becoming homeless, is needed to identify potential opportunities to enhance access and reduce fragmentation of care. MATERIALS AND METHODS VA administrative data were merged with data from the Chicago HealthLNK Data Repository to identify Veterans eligible for VA services who were homeless, or at risk of becoming homeless, in the greater Chicago metropolitan area for the years 2010-2012. RESULTS During the 3-year study period, about 208,554 Veterans were registered for care at two VA medical centers located in the City of Chicago and an adjacent suburb. Of those, 13,948 were identified as homeless or at risk of becoming homeless. Results suggest that 17% (n = 2,309) of Veterans in this sample received some or all of their care in the community. Much of the care these Veterans received was for chronic health conditions, substance use, and mental health disorders. CONCLUSIONS Veterans eligible for VA servicers who are homeless, or at risk of becoming homeless, frequently sought care in the community for a variety of chronic health conditions. Health information exchanges and partner-based registries may represent an important tool for identifying vulnerable Veteran populations while reducing duplication of care.
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Affiliation(s)
- Jason H Raad
- Department of Physical Medicine & Rehabilitation, Center of Clinical Outcomes Development and Application (CODA), University of Michigan, 2800 Plymouth Road, Building NCRC B14, Ann Arbor, MI 48109.,Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave., Hines, IL 60141
| | - Elizabeth Tarlov
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave., Hines, IL 60141.,Department of Health Systems Science, College of Nursing, University of Illinois at Chicago, 845 S. Damen Ave., MC 802, Chicago, IL 60607
| | - Abel N Kho
- Department of Medicine, Center for Health Information Partnerships, Feinberg School of Medicine, Northwestern University, 625 N Michigan Ave., 15th Floor, Chicago, IL 60611
| | - Dustin D French
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave., Hines, IL 60141.,Department of Ophthalmology, Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 440, Chicago, IL 60611,
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Siersbaek R, Ford JA, Burke S, Ní Cheallaigh C, Thomas S. Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review. BMJ Open 2021. [PMCID: PMC8039248 DOI: 10.1136/bmjopen-2020-043091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed. Design A realist review. Data sources Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019. Eligibility criteria for selecting studies The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes. Analysis Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory. Results Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention. Conclusions With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
| | | | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Clíona Ní Cheallaigh
- Clinical Medicine, Trinity College Dublin School of Medicine, Dublin, Ireland
- General Medicine, St James's Hospital, Dublin, Ireland
| | - Steve Thomas
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin, Ireland
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Wiens K, Nisenbaum R, Sucha E, Aubry T, Farrell S, Palepu A, Duhoux A, Gadermann A, Hwang SW. Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness. Med Care 2021; 59:S110-S116. [PMID: 33710082 DOI: 10.1097/mlr.0000000000001379] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario. METHODS Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs. RESULTS Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2-4. CONCLUSIONS These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.
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Affiliation(s)
- Kathryn Wiens
- Dalla Lana School of Public Health, University of Toronto
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Rosane Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Ewa Sucha
- Institute for Clinical Evaluative Sciences
| | - Tim Aubry
- School of Psychology
- Centre for Research on Educational and Community Services, University of Ottawa
| | | | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- Division of General Internal Medicine, University of British Colombia, Vancouver, BC
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- School of Population and Public Health, University of British Colombia, Vancouver, BC
| | - Stephen W Hwang
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
- Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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Minejima E, Wang J, Boettcher S, Liu L, Lou M, She RC, Wenzel SL, Spellberg B, Wong-Beringer A. Distance Between Home and the Admitting Hospital and Its Effect on Survival of Low Socioeconomic Status Population With Staphylococcus aureus Bacteremia. Public Health Rep 2021; 137:110-119. [PMID: 33715536 PMCID: PMC8721749 DOI: 10.1177/0033354921994897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Bacteremia is the presence of bacteria in the bloodstream. The objective of this study was to determine the relationship between low socioeconomic status (SES) and the epidemiology, process of care, and outcomes of patients with Staphylococcus aureus bacteremia (SAB). METHODS We conducted a multicenter, retrospective, cohort study that evaluated adult patients with SAB in 3 Los Angeles County hospitals from July 15, 2012, through May 31, 2018. We determined SES (low SES, intermediate SES, and high SES) for each patient and compared sociodemographic and epidemiologic characteristics, management of care received by patients with SAB (ie, process of care), and outcomes. We used a Cox proportional hazards model to determine predictors of 30-day mortality for each SES group. RESULTS Of 915 patients included in the sample, 369 (40%) were in the low-SES group, 294 (32%) in the intermediate-SES group, and 252 (28%) in the high-SES group. Most significant predictors of 30-day mortality in the Cox proportional hazards model were admission to an intensive care unit (hazard ratio [HR] = 9.04; 95% CI, 4.26-19.14), Pitt bacteremia score ≥4 indicating critical illness (HR = 4.30; 95% CI, 2.49-7.44), having ≥3 comorbidities (HR = 2.05; 95% CI, 1.09-3.85), and advanced age (HR = 1.03; 95% CI, 1.01-1.05). Distance between home and admitting hospital affected mortality only in the low-SES group (HR = 1.02; 95% CI, 1.00-1.02). CONCLUSIONS SES did not independently affect the outcome of SAB; however, the farther the patient's residence from the hospital, the greater the negative effect on survival in a low-SES population. Our findings underscore the need to develop multipronged, targeted public health efforts for populations that have transportation barriers to health care.
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Affiliation(s)
- Emi Minejima
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA,Los Angeles County–University of Southern California Medical Center, Los Angeles, CA, USA
| | - Joshua Wang
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Stormmy Boettcher
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Lihua Liu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mimi Lou
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Rosemary C. She
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Suzanne L. Wenzel
- Department of Adults and Healthy Aging, University of Southern California School of Social Work, Los Angeles, CA, USA
| | - Brad Spellberg
- Los Angeles County–University of Southern California Medical Center, Los Angeles, CA, USA
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA,Department of Pharmacy, Huntington Hospital, Pasadena, CA, USA,Annie Wong-Beringer, PharmD, University of Southern California School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90033, USA.
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Understanding the Associations between Smoking-Related Risk Perception, Interest in Quitting Smoking, and Interest in Lung Cancer Screening among Homeless Adult Smokers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17238817. [PMID: 33260975 PMCID: PMC7729438 DOI: 10.3390/ijerph17238817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/17/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022]
Abstract
Individuals experiencing homelessness smoke cigarettes at high rates, suffer a disproportionate incidence of lung cancer, but are unlikely to be screened to enhance early detection. Understanding correlates of lung cancer screening (LCS) interest within this vulnerable group may lend insight into prevention and treatment efforts and reduce their smoking-related morbidity and mortality. This study sought to understand how risk perception and interest in quitting smoking relate to LCS interest among homeless adults. Participants comprised a convenience sample of CO-verified current smokers (N = 310; 72.6% men, Mage = 43 + 11.7) from a homeless shelter in Dallas, TX. Participants self-reported risk perception, interest in quitting smoking, and interest in LCS. The average risk perception was 6.7 + 3.2 (range 0-10), 74.8% (n = 232) agreed or strongly agreed with interest in LCS, and 65.8% (n = 204) were interested in quitting smoking. Greater interest in quitting smoking, but not greater risk perception, was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p = 0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Results suggest that homeless smokers with an interest in quitting may be receptive to LCS: a diagnostic tool by which cancers can be caught at earlier stages and prior to metastasis. However, few in the current sample would be eligible for LCS based on current guidelines; results have implications for altered screening practices among chronic smokers experiencing homelessness.
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Enguidanos S, Cardenas V, Wenceslao M, Hoe D, Mejia K, Lomeli S, Rahman A. Health Care Provider Barriers to Patient Referral to Palliative Care. Am J Hosp Palliat Care 2020; 38:1112-1119. [DOI: 10.1177/1049909120973200] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: The purpose of this study was to explore healthcare provider-perceived challenges to HBPC patient referral and elicited providers’ feedback for overcoming these challenges. Methods: We conducted a qualitative study using semi-structured interviews with 25 Medicaid managed care providers (primary care physicians, nurse practitioners, and care managers) working in the greater Los Angeles area. Our interview protocol elicited providers’ knowledge and awareness of palliative care; perceived barriers to HBPC referral; and suggestions for overcoming these barriers. We analyzed verbatim transcripts using a grounded theory approach. Results: Themes related to referral barriers included providers’ lack of palliative care knowledge and clarity regarding referral processes, provider reluctance to refer to HBPC, and provider culture. Providers also identified patient-level barriers, including financial barriers, reluctance to have home visits, health literacy, cultural barriers, and challenges related to living situations. Themes related to methods for overcoming challenges included increased HBPC education and outreach to providers, specifically by HBPC agency staff. Conclusions: Findings from this study underscore the need for additional palliative care education for Medicaid healthcare providers. They point to the need for novel strategies and approaches to address the myriad barriers to patient identification and referral to HBPC.
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Affiliation(s)
- Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Valeria Cardenas
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Melissa Wenceslao
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Deborah Hoe
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Kiara Mejia
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
- Los Angeles County Department of Public Health, Los Angeles, CA, USA
| | - Sindy Lomeli
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Anna Rahman
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
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Kraus CK. Invited Editorial: Dedicated homeless clinics and emergency department utilization: a new horizon? J Am Coll Emerg Physicians Open 2020; 1:837-838. [PMID: 33145528 PMCID: PMC7593460 DOI: 10.1002/emp2.12135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
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Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial. Epidemiol Psychiatr Sci 2020; 29:e169. [PMID: 32996442 PMCID: PMC7576524 DOI: 10.1017/s2045796020000785] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AIMS Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use. METHODS We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed. RESULTS Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)). CONCLUSION An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.
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King C, Fisher C, Johnson J, Chun A, Bangsberg D, Carder P. Community-derived recommendations for healthcare systems and medical students to support people who are houseless in Portland, Oregon: a mixed-methods study. BMC Public Health 2020; 20:1337. [PMID: 32878612 PMCID: PMC7466795 DOI: 10.1186/s12889-020-09444-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/25/2020] [Indexed: 11/20/2022] Open
Abstract
Background People who are houseless (also referred to as homeless) perceive high stigma in healthcare settings, and face disproportionate disparities in morbidity and mortality versus people who are housed. Medical students and the training institutions they are a part of play important roles in advocating for the needs of this community. The objective of this study was to understand perceptions of how medical students and institutions can meet needs of the self-identified needs of the houseless community. Methods Between February and May 2018, medical students conducted mixed-methods surveys with semi-structured qualitative interview guides at two community-based organizations that serve people who are houseless in Portland, Oregon. Medical students approach guests at both locations to ascertain interest in participating in the study. Qualitative data were analyzed using thematic analysis rooted in an inductive process. Results We enrolled 38 participants in this study. Most participants were male (73.7%), white (78.9%), and had been houseless for over a year at the time of interview (65.8%). Qualitative themes describe care experiences among people with mental health and substance use disorders, and roles for medical students and health-care institutions. Specifically, people who are houseless want medical students to 1) listen to and believe them, 2) work to destigmatize houselessness, 3) engage in diverse clinical experiences, and 4) advocate for change at the institutional level. Participants asked healthcare institutions to use their power to change laws that criminalize substance use and houselessness, and build healthcare systems that take better care of people with addiction and mental health conditions. Conclusions Medical students, and the institutions they are a part of, should seek to reduce stigma against people who are houseless in medical systems. Additionally, institutions should change their approaches to healthcare delivery and advocacy to better support the health of people who are houseless.
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Affiliation(s)
- Caroline King
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Cameron Fisher
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Jacob Johnson
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Arum Chun
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Bangsberg
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Paula Carder
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
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Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study. Public Health 2020; 185:224-231. [DOI: 10.1016/j.puhe.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
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Schaffer KB, Wang J, Nasrallah FS, Bayat D, Dandan T, Ferkich A, Biffl WL. Disparities in triage and management of the homeless and the elderly trauma patient. Inj Epidemiol 2020; 7:39. [PMID: 32654664 PMCID: PMC7358191 DOI: 10.1186/s40621-020-00262-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community. Methods A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed. Results Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates. Conclusions Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.
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Affiliation(s)
- Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Jiayan Wang
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Tala Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Anthony Ferkich
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
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Wang LY, Lin LP, Chen YC, Wang TW, Lin JD. Correlates of Depressive Symptoms among Middle-Aged and Older Homeless Adults Using the 9-Item Patient Health Questionnaire. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134754. [PMID: 32630635 PMCID: PMC7370065 DOI: 10.3390/ijerph17134754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 01/01/2023]
Abstract
This study investigates the screening for depressive symptoms among middle-aged and older homeless adults based on Patient Health Questionnaire-9 (PHQ-9) and examines the possible factors associated with their major depressive symptoms. A cross-sectional survey was employed, and research subjects included 129 homeless people aged 45 years old and over in Taipei Wanhua District and Taipei Main Station. We used a structured questionnaire and face-to-face interview conducted by three social workers to collect data in the analyses. The content of the questionnaire included an informed consent form, demographic characteristics, enabling and need factors of healthcare, and PHQ-9 of homeless people. Results revealed that 15.5% respondents were free of depressive symptoms, 16.3% had mild level (score 5–9), 31.8% had moderate level (score 10–14), 26.4% had moderately severe level (score 15–19), and 10.1% had severe level of depressive symptoms (score 20–27). Adopting a PHQ-9 score 10 as a cut-off point for major depressive symptoms, 68.3% of middle-aged and older homeless adults were the cases needing to be referred to healthcare settings for further recheck in the near future. A multiple regression analysis found gender, age, and usage of psychiatric outpatient care were associated with major depressive symptom occurrence. The female participants were less likely to have major depressive symptoms than the male participants (OR = 0.29, 95% CI = 0.09–0.96). The elderly participants were more likely to have major depressive symptoms than the aged 45–54 years (OR = 5.29, 95% CI = 1.44–19.41). Those participants who have ever used psychiatric outpatient care were significantly more correlated with the occurrence of major depressive symptoms than their counterparts (OR = 3.65, 95% CI = 1.46–9.09). The present study suggests that in the future health policy should eliminate the risk factors of depressive symptoms and improve mental healthcare access, to improve the health and wellbeing of the homeless population.
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Affiliation(s)
- Lin-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 144, Taiwan; (Y.-C.C.); (T.-W.W.)
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 144, Taiwan; (Y.-C.C.); (T.-W.W.)
| | - Jin-Ding Lin
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence: ; Tel.: +886-2-2636-0303-1816
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Dickins KA, Buchholz SW, Ingram D, Braun LT, Hamilton RJ, Earle M, Karnik NS. Supporting Primary Care Access and Use among Homeless Persons. SOCIAL WORK IN PUBLIC HEALTH 2020; 35:335-357. [PMID: 32865153 DOI: 10.1080/19371918.2020.1809589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.
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Affiliation(s)
- Kirsten A Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research , Boston, Massachusetts, USA
| | | | - Diana Ingram
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Lynne T Braun
- Rush University College of Nursing , Chicago, Illinois, USA
| | | | - Melinda Earle
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Niranjan S Karnik
- Rush Medical College Department of Psychiatry, Rush University College of Nursing , Chicago, Illinois, USA
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Iwundu CN, Agrawal P, Businelle MS, Kendzor DE, Reitzel LR. Predictors of Overnight and Emergency Treatment among Homeless Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4271. [PMID: 32549281 PMCID: PMC7345623 DOI: 10.3390/ijerph17124271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 12/02/2022]
Abstract
High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.
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Affiliation(s)
- Chisom N. Iwundu
- Department of Rehabilitation and Health Services, College of Public and Health, University of North Texas Services, Denton, TX 76203, USA
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
| | - Pooja Agrawal
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- School of Medicine, University of Texas Medical Branch, Galveston, TX 78701, USA
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Lorraine R. Reitzel
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- HEALTH Research Institute, University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA
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Djuric CM, Vottero B. Primary care services tailored for adult and adolescent homeless persons: a scoping review protocol. JBI Evid Synth 2020; 18:2031-2037. [DOI: 10.11124/jbisrir-d-19-00331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Shoemaker ES, Kendall CE, Mathew C, Crispo S, Welch V, Andermann A, Mott S, Lalonde C, Bloch G, Mayhew A, Aubry T, Tugwell P, Stergiopoulos V, Pottie K. Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study. PLoS One 2020; 15:e0231758. [PMID: 32298388 PMCID: PMC7162520 DOI: 10.1371/journal.pone.0231758] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 04/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. Methods We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. Findings Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. Interpretation The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.
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Affiliation(s)
- Esther S. Shoemaker
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Claire E. Kendall
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Institute du Savoir Montfort, Ottawa, ON, Canada
| | | | | | - Vivian Welch
- Bruyère Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Anne Andermann
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- St Mary’s Research Centre, St Mary’s Hospital, Montreal, QC, Canada
| | - Sebastian Mott
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | | | - Gary Bloch
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Inner City Health Associates, Toronto, ON, Canada
| | | | - Tim Aubry
- School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tugwell
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Vicky Stergiopoulos
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addictions and Mental Health, Toronto, ON, Canada
| | - Kevin Pottie
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- * E-mail:
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Dickins K, Buchholz SW, Ingram D, Hamilton RJ, Braun LT, Karnik NS, Earle M. "Now that you've got that coverage": Promoting use of a regular source of primary care among homeless persons. J Am Assoc Nurse Pract 2019; 33:158-166. [PMID: 31738276 DOI: 10.1097/jxx.0000000000000319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/06/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The growing number of homeless persons in the United States demonstrates greater morbidity and mortality than the population as a whole. Homeless persons are often without a regular source of primary care. Homeless persons use emergency departments and are hospitalized at higher rates than nonhomeless persons. In 2010, the enactment of the Affordable Care Act expanded access to primary care services. Nurse practitioners were at the forefront of its subsequent implementation. PURPOSE The purpose of this qualitative study was to explore the factors that influence establishing and maintaining a regular source of primary care among homeless persons. METHODOLOGICAL ORIENTATION In 2017, semistructured interviews were conducted in a federally qualified health center that serves predominately homeless persons. SAMPLE A purposive convenience sample included adult health center users (N = 20). The majority of participants were insured (90%), African American (70%), and male (65%). CONCLUSIONS Thematic analysis revealed five facilitators: sense of community, mutual patient-provider respect, financial assurance, integrated health services, and patient care teams. To establish and maintain use of a regular primary care source, homeless persons desire to experience a sense of community, feel respected by their provider/staff, and have certainty that costs will not exceed their capacity to pay. Integrated care models that leverage a multidisciplinary team approach support the use of a regular primary care source. IMPLICATIONS FOR PRACTICE Actualizing achievable strategies that promote the consistent use of a regular primary care source can reduce use of avoidable emergency and hospital-based services, thereby improving health outcomes among homeless persons.
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Affiliation(s)
- Kirsten Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research, Boston, Massachusetts
| | - Susan W Buchholz
- Department of Adult Health and Gerontological Nursing, Rush University College of Nursing, Chicago, Illinois
| | - Diana Ingram
- Rush University College of Nursing, Chicago, Illinois
| | - Rebekah J Hamilton
- Department of Women, Children and Family Nursing, Rush University College of Nursing, Chicago, Illinois
| | - Lynne T Braun
- Department of Internal Medicine, Department of Adult Health and Gerontological Nursing, Rush University College of Nursing, Chicago, Illinois
- Rush Heart Center for Women, Chicago, Illinois
| | - Niranjan S Karnik
- Department of Psychiatry, The Cynthia Oudejans Harris, MD
- Community Behavioral Health, Rush Medical College, Chicago, Illinois
- Department of Psychiatry
| | - Melinda Earle
- Department of Women, Children and Family Nursing, Rush University College of Nursing, Chicago, Illinois
- Transformative Leadership: Systems Program
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