Shelter-based convalescence for homeless adults in Amsterdam: a descriptive study

Medical centres for the homeless in Hamburg - consultation reasons and diagnoses compared to primary care patients in the regular health care system

BACKGROUND

In Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany's regular health care system.

METHODS

From 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH's software and analysed descriptively for the years 2013 to 2020.

RESULTS

A total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: "Psychological behavioural disorder due to alcohol" and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for "not making use of" the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013-2020 46% to 73% of the 8.380 MCH patients had no health care insurance.

CONCLUSION

Patients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from "typical" symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system.

The Correlation between Neck Pain and Disability, Forward Head Posture, and Hyperkyphosis with Opium Smoking: A Cross-Sectional Study from Iran

Opium smoking has been a common practice in Iran for many years, with people often smoking for long hours. During the COVID-19 pandemic, there was an increase in opium smoking due to false beliefs about its protective effects against COVID-19 infection. In this study, we aimed to examine the association between the non-ergonomic positions associated with traditional opium smoking in Iran and the development of neck pain and disability, forward head posture (FHP), and hyperkyphosis (HK). In this cross-sectional, correlational study, a total of 120 individuals who smoked opium were selected based on the inclusion criteria. They were interviewed about their addiction profile using the Lite version of the Addiction Severity Index and the Leeds Dependence Questionnaire. The presence of neck pain and disability was also evaluated using the Visual Analog Scale and the Neck Disability Index. The participants were examined for FHP via side-view photography and for HK using a flexible ruler. Data were analyzed using correlation coefficient tests and stepwise linear regression analysis. Based on the results, homelessness, the lifetime duration of opium smoking (in months), the duration of daily opium smoking (in minutes), and the severity of drug dependence had significant relationships with the severity of neck pain, neck disability, FHP, and HK. Homelessness was the strongest predictor of neck pain and disability (R2 = 0.367, p < 0.001), FHP (R2 = 0.457, p < 0.001), and HK (R2 = 0.476, p < 0.001), followed by the lifetime duration of opium smoking and the duration of daily opium smoking, respectively, in which R2 increased to 0.505 (p = 0.011), 0.546 (p = 0.022), and 0.570 (p = 0.004) with the addition of two other variables. Overall, an increase in the duration of sitting in non-ergonomic positions could lead to neck pain and disability, FHP, and HK due to the non-neutral posture of opium smokers.

Evaluating the perceived added value of a threefold intervention to improve palliative care for persons experiencing homelessness: a mixed-method study among social service and palliative care professionals

BACKGROUND

Palliative care for persons experiencing homelessness who reside in social service facilities is often late or lacking. A threefold intervention was implemented to improve palliative care for this population by increasing knowledge and collaboration between social service and palliative care professionals. This consultation service comprised: 1) consultations between social service professionals and palliative care professionals; 2) multidisciplinary meetings involving these professionals; and 3) training of these professionals. This study aims to evaluate the perceived added value of this threefold consultation service in three regions in the Netherlands.

METHODS

A mixed-methods evaluation study using structured questionnaires for consultants, requesting consultants, and attendees of multidisciplinary meetings, semi-structured group and individual interviews with social service and palliative care professionals involved, weekly diaries filled out by consultants, and an implementation diary. Qualitative data were analyzed following the principles of thematic analysis. Quantitative data were analyzed descriptively.

RESULTS

Thirty-four consultations, 22 multidisciplinary meetings and 9 training sessions were studied during the implementation period of 21 months. Social service professionals made up the majority of all professionals reached by the intervention. In all regions the intervention was perceived to have added value for collaboration and networks of social service and palliative care professionals (connecting disciplines reciprocally and strengthening collaborations), the competences of especially social service professionals involved (competency in palliative care provision, feeling emotionally supported in complex situations), and the quality and timing of palliative care (more focus on quality of life and dying, advance care planning and looking ahead, and greater awareness of death and palliative care).

CONCLUSIONS

The threefold consultation service particularly helps social service professionals connect with palliative care professionals. It helps them to identify palliative care needs in good time and to provide qualitatively better palliative care to persons experiencing homelessness.

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

Background

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

Methods

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

Results

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

Strengths and limitations

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

Future work

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

Funding

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

Understanding Dermatologic Concerns Among Persons Experiencing Homelessness: A Scoping Review and Discussion for Improved Delivery of Care

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Design Considerations for the Development and Implementation of a Medical Respite for Older Adults Experiencing Homelessness in Metro Vancouver

BACKGROUND

Older persons with lived or living experience of homelessness (PWLEs) often live with complex physical and/or mental health conditions which are challenged by poor access to health services, especially primary care. To fill the gap in the continuum of care following hospital discharge for PWLEs, medical respite provides health and shelter support for PWLEs who do not have acute care needs that qualify for a stay in a hospital bed, yet are too sick or frail to recover on the streets or in a traditional shelter.

OBJECTIVE

This study examines how a medical respite could be designed for older PWLEs in Metro Vancouver, BC.

RESEARCH DESIGN

Using a community-based participatory research approach, in-depth interviews and focus groups were conducted with PWLE (n=15) and service provider (n=11) participants.

RESULTS

Participants offered rich suggestions about (a) the culture of the medical respite, (b) the physical design of a medical respite, (c) individuals who should be involved in medical respite delivery, (d) services a medical respite should provide, and (e) who the medical respite should serve.

CONCLUSIONS

When designing a medical respite for older PWLEs, considerations include providing an environment where patients can rest, but also feel safe and be surrounded by persons who they trust and who care for them. Developing a medical respite that adheres to the tenets of trauma-informed and patient-centered care acknowledges the mistrust and traumatization that often accompanies homeless patients presenting to health care.

Healthcare inequities and barriers to access for homeless individuals: a qualitative study in Barcelona (Spain)

BACKGROUND

In Spain, homeless individuals have lower perceived quality of health than the rest of the population and their life expectancy is 30 years lower than the national average. While the Spanish health system provides universal access and coverage, homeless individuals do not access or use public care enough to maintain their health. The objective of this study is to determine if homeless individuals can access public health services in conditions of equality with the rest of the population, as established in healthcare legislation, and to better understand the causes of observed inequalities or inequities of access.

METHODS

A detailed qualitative study was carried out in the city of Barcelona (Spain) from October 2019 to February 2020. A total of nine open and in-depth interviews were done with homeless individuals along with seven semi-structured interviews with key informants and two focus groups. One group was composed of eight individuals who were living on the street at the time and the other consisted of eight individuals working in healthcare and social assistance.

RESULTS

The participants indicated that homeless individuals tend to only access healthcare services when they are seriously ill or have suffered some kind of injury. Once there, they tend to encounter significant barriers that might be 1) administrative; 2) personal, based on belief that that will be poorly attended, discriminated against, or unable to afford treatment; or 3) medical-professional, when health professionals, who understand the lifestyle of this population and their low follow-through with treatments, tend towards minimalist interventions that lack the dedication they would apply to other groups of patients.

CONCLUSIONS

The conclusions derived from this study convey the infrequent use of health services by homeless individuals for reasons attributable to the population itself, to healthcare workers and to the entire healthcare system. Accordingly, to reduce inequities of access to these services, recommendations to healthcare service providers include adapting facilities to provide more adequate care for this population; increasing sensitivity/awareness among healthcare workers; developing in situ care systems in places where the homeless population is most concentrated; and establishing healthcare collaboration agreements with entities that work with this population.

End-of-life care for homeless people in shelter-based nursing care settings: A retrospective record study

BACKGROUND

Homeless people experience multiple health problems and early mortality. In the Netherlands, they can get shelter-based end-of-life care, but shelters are predominantly focused on temporary accommodation and recovery.

AIM

To examine the characteristics of homeless people who reside at the end-of-life in shelter-based nursing care settings and the challenges in the end-of-life care provided to them.

DESIGN

A retrospective record study using both quantitative and qualitative analysis methods.

SETTING/PARTICIPANTS

Two Dutch shelter-based nursing care settings. We included 61 homeless patients who died between 2009 and 2016.

RESULTS

Most patients had somatic (98%), psychiatric (84%) and addiction problems (90%). For 75% of the patients, the end of life was recognised and documented; this occurred 0-1253 days before death. For 26%, a palliative care team was consulted in the year before death. In the three months before death, 45% had at least three transitions, mainly to hospitals. Sixty-five percent of the patients died in the shelter, 27% in a hospital and 3% in a hospice. A quarter of all patients were known to have died alone. Documented care difficulties concerned continuity of care, social and environmental safety, patient-professional communication and medical-pharmacological alleviation of suffering.

CONCLUSIONS

End-of-life care for homeless persons residing in shelter-based nursing care settings is characterised and challenged by comorbidities, uncertain prognoses, complicated social circumstances and many transitions to other settings. Multilevel end-of-life care improvements, including increased interdisciplinary collaboration, are needed to reduce transitions and suffering of this vulnerable population at the end of life.

Low prevalence of resistance genes in sheltered homeless population in Marseille, France, 2014-2018

Objectives: The present study has explored the prevalence and potential factors contributing to the presence of nasal/pharyngeal resistant genes in homeless people. Methods: During the winters 2014-2018, we enrolled sheltered homeless adults and controls and collected nasal/pharyngeal samples. Sixteen antibiotic resistance genes (ARGs), including genes encoding for beta-lactamases and colistin-resistance genes, were searched by real-time polymerase chain reaction (qPCR) performed directly on respiratory samples and followed by conventional PCR and sequencing. Results: Over a 5-year period, using qPCR, we identified in homeless group (n=715) the presence of bla _TEM (396/710, 54.7%), bla_SHV (27/708, 3.6%), bla _OXA-23 (1/708, 0.1%), while other genes including colistin-resistance genes (mcr-1 to mcr-5) were absent. We found a significantly higher proportion of ARG carriage among controls (74.1%) compared to homeless population (57.1%), p=0.038. Tobacco smoking (OR=4.72, p<0.0001) and respiratory clinical signs (OR=4.03, p=0.002) were most prevalent in homeless people, while vaccination against influenza (OR=0.31, p=0.016) was lower compared to controls. Among homeless people, type of housing (shelter A versus B, OR=1.59, p=0.006) and smoking tobacco (smoker versus non-smoker, OR=0.55, p=0.001) were independent factors associated with ARG carriage. By sequencing, we obtained a high diversity of bla _TEM and bla_SHV in both populations. Conclusion: The lower risk for ARGs in the homeless population could be explained by limited access to health care and subsequently reduced exposure to antibiotics.

Health supports needed for homeless persons transitioning from hospitals

Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow-up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after-care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma-informed care and patient- or client-centred care approaches are discussed.

Access to palliative care for homeless people: complex lives, complex care

BACKGROUND

People experiencing homelessness often encounter progressive incurable somatic diseases in combination with psychiatric and psychosocial problems, and many need palliative care at the end of their lives. Little is known about how palliative care for this group can be started in good time and provided optimally. The objective of this paper is to give insight into the extent people experiencing homelessness have access to good palliative care.

METHODS

Qualitative in-depth interviews were held to reconstruct the cases of 19 people experiencing homelessness in the Netherlands. Eight cases concerned persons being in the palliative phase (using the surprise question) and the other 11 cases concerned persons recently died after a period of ill health due to somatic illness. We used purposive sampling until data saturation was reached. The total number of interviews was 52. All interviews were transcribed verbatim and analysed inductively.

RESULTS

Three key themes were: 'late access', 'capricious trajectory' and 'complex care'. The first key theme refers to the often delayed start of palliative care, because of the difficulties in recognizing the need for palliative care, the ambivalence of people experiencing homelessness about accepting palliative care, and the lack of facilities with specific expertise in palliative care for them. The second key theme refers to the illness trajectory, which is often capricious because of the challenging behaviour of people experiencing homelessness, an unpredictable disease process and a system not being able to accommodate or meet their needs. The third key theme refers to the complexity of their care with regard to pain and symptom control, psychosocial and spiritual aspects, and the social network.

CONCLUSIONS

The care for in the palliative phase does not satisfy the core requirements of palliative care since there are bottlenecks regarding timely identification, the social network, and the assessment and management of physical symptoms and psychosocial and spiritual care needs. Education in palliative care of outreach professionals, training staff in shelters in the provision of palliative care, and building a network of palliative care specialists for people experiencing homelessness.

The Views of Homeless People and Health Care Professionals on Palliative Care and the Desirability of Setting Up a Consultation Service: A Focus Group Study

CONTEXT

Palliative care for homeless people is often given late, if at all. Professionals in both palliative care and shelter care are often insufficiently equipped to provide this complex care.

OBJECTIVES

To provide insights into the palliative care experiences of professionals and homeless people, including barriers and facilitators to care, and to investigate whether a consultative function can help improve palliative care for homeless people.

METHODS

Six focus groups were included; four with professionals (n = 19) and two with severely ill homeless people (n = 15). Professionals were sampled purposively in organizations providing (palliative) care to the homeless. Homeless people were recruited by opportunity sampling.

RESULTS

Palliative care for homeless people is especially complex and differs substantially from regular palliative care. It differs greatly among professionals, institutions, and cities. Homeless people get less autonomy than they would like. Homeless people and professionals have different perceptions of the care provided. Trusting relationships between professionals and homeless people is essential and easily accessible, and flexible care is needed. Consultation, in particular involving exchange of expertise between professionals, can provide added value to professionals. Homeless people consider consultation primarily as an opportunity to train professionals to show more understanding, provide tailored palliative care, and enhance professional collaboration. The local situation, characteristics of a consultant, and role of a consultant in providing information and education must be considered when developing the consultation process.

CONCLUSION

Consultation can play an important role in improving palliative care by linking disciplines, providing support to professionals and appropriate palliative care to homeless people.

Epidemiology of respiratory pathogen carriage in the homeless population within two shelters in Marseille, France, 2015-2017: cross sectional 1-day surveys

Objectives

To assess risk factors for respiratory tract infection symptoms and signs in sheltered homeless people in Marseille during the winter season, including pathogen carriage.

Methods

Data on 479 male participants within two shelters who completed questionnaires and a total of 950 nasal and pharyngeal samples were collected during the winters of 2015–2017. Respiratory pathogen carriage including seven viruses and four bacteria was assessed by quantitative PCR.

Results

The homeless population was characterized by a majority of individuals of North African origin (300/479, 62.6%) with a relatively high prevalence of chronic homelessness (175/465, 37.6%). We found a high prevalence of respiratory symptoms and signs (168/476, 35.3%), a very high prevalence of bacterial carriage (313/477, 65.6%), especially Haemophilus influenzae (280/477, 58.7%), and a lower prevalence of virus carriage (51/473, 10.8%) with human rhinovirus being the most frequent (25/473, 5.3%). Differences were observed between the microbial communities of the nose and throat. Duration of homelessness (odds ratio (OR) 1.77, p 0.017), chronic respiratory diseases (OR 5.27, p <0.0001) and visiting countries of origin for migrants (OR 1.68, p 0.035) were identified as independent risk factors for respiratory symptoms and signs. A strong association between virus (OR 2.40, p 0.012) or Streptococcus pneumoniae (OR 2.32, p 0.014) carriage and respiratory symptoms and signs was also found.

Conclusions

These findings allowed identification of the individuals at higher risk for contracting respiratory tract infections to better target preventive measures aimed at limiting the transmission of these diseases in this setting.

Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature

This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.

Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care

Background

Homeless people often suffer from complex and chronic comorbidities, have high rates of morbidity and die at much younger ages than the general population. Due to a complex combination of physical, psychosocial and addiction problems at the end of life, they often have limited access to palliative care. Both the homeless and healthcare providers experience a lot of barriers. Therefore, providing palliative care that fits the needs and concerns of the homeless is a challenge to healthcare providers. This systematic review aims to summarize evidence about the concerns, palliative care needs and preferences of homeless people, as well as barriers and facilitators for delivering high quality palliative care.

Methods

PubMed, Embase, PsycINFO, CINAHL and Web of Science were searched up to 10 May 2016. Included were studies about homeless people with a short life expectancy, their palliative care needs and the palliative care provided, that were conducted in Western countries. Data were independently extracted by two researchers using a predefined extraction form. Quality was assessed using a Critical Appraisal instrument. The systematic literature review was based on the PRISMA statement.

Results

Twenty-seven publications from 23 different studies met the inclusion criteria; 15 studies were qualitative and eight were quantitative. Concerns of the homeless often related to end-of-life care not being a priority, drug dependence hindering adequate care, limited insight into their condition and little support from family and relatives. Barriers and facilitators often concerned the attitude of healthcare professionals towards homeless people. A respectful approach and respect for dignity proved to be important in good quality palliative care.

Conclusions

A patient-centred, flexible and low-threshold approach embodying awareness of the concerns of homeless people is needed so that appropriate palliative care can be provided timely. Training, education and experience of professionals can help to accomplish this.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0320-6) contains supplementary material, which is available to authorized users.

Mortality and psychiatric disorders among public mental health care clients in Utrecht: a register-based cohort study

BACKGROUND

Different studies have shown similar or even lower mortality among homeless persons with compared to homeless persons without a severe mental disorder.

AIMS

To clarify the association between presence of a psychiatric diagnosis and mortality among the socially marginalized.

METHODS

The Public Mental health care (PMHc) is a legal task of the municipal authority aiming at prevention and intervention in case of (imminent) homelessness among persons with a serious shortage of self-sufficiency. The data of PMHc clients (N=6,724) and personally matched controls (N=66,247) were linked to the registries of Statistics Netherlands and analysed in a Cox model.

RESULTS

The increased mortality among PMHc clients, compared to the general population (HR=2.99, 95%-CI: 2.63-3.41), was associated with a broad range of death causes. Clients with a record linkage to the Psychiatric Case Registry Middle Netherlands ('PMHc+') had an increased risk of suicide (HR=2.63, 0.99-7.02, P=0.052), but a lower risk of natural death causes (HR=0.71, 0.54-0.92, P=0.011), compared to clients without this record linkage ('PMHc-'). Compared to controls, however, 'PMHc-' clients experienced substantially increased risks of suicide (HR=3.63, 1.42-9.26, P=0.007) and death associated with mental and behavioural disorders (ICD-10 Ch.V) (HR=7.85, 3.54-17.43, P<0.001).

CONCLUSION

Psychiatric services may deliver an important contribution to the prevention of premature natural death among the socially marginalized.

KEYPHRASES

The earlier observed lower mortality among vulnerably housed and homeless persons with a psychiatric diagnosis compared to vulnerably housed and homeless persons without a psychiatric diagnosis appears to be due to a significantly lower risk of natural causes of death. Compared to controls from the general population, vulnerably housed and homeless persons without registered diagnosis at a local psychiatric service have a significantly increased mortality associated both with natural death causes and with suicide and death due to mental and behavioural disorders. Services for mental health care may deliver an important contribution to the prevention of premature death due to somatic disorders among the socially marginalized.

Health, drugs and service use among deprived single men: comparing (subgroups) of single male welfare recipients against employed single men in Amsterdam

OBJECTIVES

To aid public health policy in preventing severe social exclusion (like homelessness) and promoting social inclusion (like labour market participation), we aimed to quantify (unmet) health needs of an expectedly vulnerable population on which little was known about: single male welfare recipients (SIM-welfare). One of the main policy questions was: is there need to promote access to healthcare for this specific group?

DESIGN

A cross-sectional study incorporating peer-to-peer methodology to approach and survey SIM-welfare. Sociodemographics, prevalence of ill health, harmful drug use and healthcare utilisation for subgroups of SIM-welfare assessed with a different distance to the labour market and exposed to different reintegration policy were described and compared against single employed men (SIM-work).

SETTING

Men between the age of 23 and 64, living in single person households in Amsterdam.

PARTICIPANTS

A random and representative sample of 472 SIM-welfare was surveyed during 2009-2010. A reference sample of 212 SIM-work was taken from the 2008 Amsterdam Health Survey.

OUTCOME MEASURES

Standardised instruments were used to assess self-reported ill somatic and mental health, harmful drug use and service use.

RESULTS

SIM-welfare are mostly long-term jobless, low educated, older men; 70% are excluded from re-employment policy due to multiple personal barriers. Health: 50% anxiety and depression; 47% harmful drug use; 41% multiple somatic illnesses. Health differences compared with SIM-work: (1) controlled for background characteristics, SIM-welfare report more mental (OR 4.0; 95% CI 2.1 to 4.7) and somatic illnesses (OR 3.1; 95% CI 2.7 to 6.0); (2) SIM-welfare assessed with the largest distance to the labour market report most combined health problems. Controlled for ill health, SIM-welfare are more likely to have service contacts than SIM-work.

CONCLUSIONS

SIM-welfare form a selection of men with disadvantaged human capital and health. Findings do not support a need to improve access to healthcare. The stratification of welfare clients distinguishes between health needs.

Reaching out to the forgotten: providing access to medical care for the homeless in Italy

Background

A program for outpatient and intermediate inpatient care for the homeless was pioneered by the humanitarian organization Médecins Sans Frontières (MSF) in Milan, Italy, during the winter of 2012-2013. We aimed to document the characteristics and clinical management of inpatients and outpatients seen during this program.

Methods

A clinic providing outpatient and intermediate inpatient care (24 bed capacity) was set up in an existing homeless hostel. Patients were admitted for post-hospitalization intermediate care or for illnesses not requiring secondary care. This study was a retrospective audit of the routine program data.

Results

Four hundred and fifty four individuals presented for outpatient care and 123 patients were admitted to inpatient intermediary care. On average one outpatient consultation was conducted per patient per month, most for acute respiratory tract infections (39.8%; 522/1311). Eleven percent of all outpatients suffered from an underlying chronic condition and 2.98% (38/1311) needed referral to emergency services or secondary care facilities. Most inpatients were ill patients referred through public reception centers (72.3%; 89/123), while 27.6% (34/123) were post-hospitalization patients requiring intermediate care. Out of all inpatients, 41.4% (51/123) required more than 1 week of care and 6.5% (8/123) needed counter-referral to secondary care.

Conclusions

The observed service usage, morbidity patterns, relatively long lengths of stay, high referral completion and need for counter-referrals, all reflect the important gap-filling role played by an intermediate care facility for this vulnerable population. We recommend that in similar contexts, medical non-governmental organizations (NGOs) focus on the setup of inpatient intermediary care services; while outpatient services are covered by the public health system.

Mortality and life expectancy in homeless men and women in Rotterdam: 2001-2010

Background

Data on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city.

Methods

Based on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy.

Results

During follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95–7.82) as compared to men (RR 3.31, 95% CI 2.91–3.77), and decreased with age (RR 7.67, 95% CI 6.87–8.56 for the age group 20–44 and RR 1.63, 95% CI 1.41–1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1–12.9) and 15.9 (95% CI 10.3–21.5) years lower for homeless men and women compared to men and women in the general population respectively.

Conclusion

Homeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.

Correlates of frailty among homeless adults

Frailty, a relatively unexplored concept among vulnerable populations, may be a significant issue for homeless adults. This cross-sectional study assessed correlates of frailty among middle age and older homeless adults (N = 150, 40-73). A Pearson (r) bivariate correlation revealed a weak relationship between frailty and being female (r = .230, p < .01). Significant moderate negative correlations were found between frailty and resilience (r = -.395, p < .01), social support (r = -.377, p < .01), and nutrition (r = -.652, p < .01). Furthermore, Spearman's rho (r s) bivariate correlations revealed a moderate positive relationship between frailty and health care utilization (r(s) = .444, p < .01). A stepwise backward linear regression analysis was conducted and in the final model, age, gender, health care utilization, nutrition, and resilience were significantly related to frailty. Over the next two decades, there is an anticipated increase in the number of homeless adults which will necessitate a greater understanding of the needs of this hard-to-reach population.

Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study

BACKGROUND

The increased mortality of homeless people compared with non-homeless people might be linked to psychiatric disorders. However, homeless people are, because of their insufficient accommodation, difficult to sample and monitor, which has limited previous studies. We aimed to assess registered psychiatric disorders, mortality, and predictors of mortality in the homeless shelter population in Denmark.

METHODS

We did a nationwide, prospective, register-based cohort study of homeless people aged 16 years and older who were registered in the Danish Homeless Register between Jan 1, 1999, and Dec 31, 2009. We calculated the proportion of registered psychiatric disorders, overall and cause-specific standardised mortality ratio (SMR), and life expectancy. Hazard ratios (HRs) were used to assess predictors of death.

FINDINGS

32,711 homeless people (23,040 men and 9671 women) were included in the study population. 14,381 men (62·4%) and 5632 women (58·2%) had registered psychiatric disorders, and 11,286 men (49·0%) and 3564 women (36·9%) had a substance abuse diagnosis. During the study period, 3839 men (16·7%) and 951 women (9·8%) died. The overall SMR for men was 5·6 (95% CI 5·4-5·8) and for women was 6·7 (6·2-7·1), and external causes accounted for 1161 (27·9%) of 4161 deaths for which information on the cause was available. Remaining life expectancy at age 15-24 years was 21·6 years (95% CI 21·2-22·1) and 17·4 years (16·4-18·5) lower for homeless men and women, respectively, than the general population. Registered substance abuse disorder was associated with the highest mortality risk compared with no psychiatric contact registered (adjusted HR 1·4, 95% CI 1·3-1·5 for men; 1·7, 1·4-2·1 for women).

INTERPRETATION

Health problems are extensive in the homeless shelter population and there is an urgent need for more sustained efforts to reduce the high morbidity and mortality, especially from external causes. Register data is an important resource to supplement existing knowledge on homeless people with more valid and detailed information.

FUNDING

The Danish Council for Independent Research.