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Lambert M, König H, Karow A, König HH, Rohenkohl A, Luedecke D, Schröter R, Finter C, Tlach L, Schindler A, Peter H, Scherer M, Mews C, Härter M, Bindt C, Löwe B, Briken P, Peper H, Schweiger M, Mösko M, Bock T, Deister A, Correll CU, Ozga AK, Pepić A, Zapf A, Gallinat J, Peth J, Konnopka A, Schulz H. Stepped, evidence-based and integrated care service model vs. usual care for mental disorders: A randomized controlled trial (RECOVER). Psychiatry Res 2024; 339:116007. [PMID: 38865905 DOI: 10.1016/j.psychres.2024.116007] [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] [Received: 04/16/2024] [Revised: 05/28/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024]
Abstract
Stepped, evidence-based and integrated care service models have the potential to be used as a reference for mental health services. RECOVER aimed to evaluate cost savings, effectiveness, and cost-effectiveness of such a model within a two arm, assessor- and data analysist-blinded RCT in Hamburg, Germany. Participants aged 16-79 years with mental disorders were randomly assigned either to RECOVER or treatment as usual (TAU). Primary outcomes comprised costs, effectiveness (combined symptoms, functioning, quality of life), and cost-effectiveness, hierarchically ordered. Outcomes were evaluated according to the ITT principle, group differences regarding costs with adjusted generalized linear models, effectiveness with ANCOVA models, and cost-effectiveness with the incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curves (CEACs). Between 1/1/2018 and 12/31/2020, n = 891 were finally included (n = 477 in RECOVER, n = 444 in TAU). RECOVER was associated with significantly lower annual total costs (-22 %), health and social care costs (-25 %) and hospital costs (-50 %). Effectiveness analyses showed a significantly better outcome for RECOVER with the fully imputed data . The CEACs descriptively demonstrated that RECOVER was cost-effective with a probability of >95 %. Treatment in RECOVER resulted in substantial cost reductions with better cost-effectiveness. RECOVER can be recommended as a reference model for comprehensive and integrated mental health services.
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Affiliation(s)
- Martin Lambert
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Hannah König
- Institute of Health Economics and Health Services Research, UKE, Germany
| | - Anne Karow
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany.
| | - Hans-Helmut König
- Institute of Health Economics and Health Services Research, UKE, Germany
| | - Anja Rohenkohl
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Daniel Luedecke
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Romy Schröter
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Constanze Finter
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Lisa Tlach
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Andreas Schindler
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Helmut Peter
- Falkenried MVZ GmbH, Ambulatory Healthcare Center for Psychotherapy, Psychiatry and Psychosomatic, Falkenried 7 20251 Hamburg, Germany
| | - Martin Scherer
- Department of General Practice/Primary Care, UKE, Hamburg, Germany
| | - Claudia Mews
- Department of General Practice/Primary Care, UKE, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, UKE, Hamburg, Germany
| | - Carola Bindt
- Department of Child- and Youth Psychiatry, Psychotherapy and Psychosomatics, UKE, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, UKE, Hamburg, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, UKE, Hamburg, Germany
| | - Heike Peper
- Chamber for Psychotherapists Hamburg, Hallerstr. 61 20146 Hamburg, Germany
| | - Michael Schweiger
- ARINET GmbH, Service-Provider for vocational rehabilitation, Schauenburgerstr. 6 20095 Hamburg, Germany
| | - Mike Mösko
- Department of Medical Psychology, Research Group on Migration and Psychosocial Health, UKE, Hamburg, Germany
| | - Thomas Bock
- Irre menschlich Hamburg, UKE, Hamburg, Germany
| | - Arno Deister
- Center for Psychosocial Medicine, Medical Center Itzehoe, Robert Koch Str. 2 25524 Itzehoe, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, UKE, Hamburg, Germany
| | - Amra Pepić
- Institute of Medical Biometry and Epidemiology, UKE, Hamburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, UKE, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52 20246 Hamburg, Germany
| | - Judith Peth
- Department of Medical Psychology, UKE, Hamburg, Germany
| | - Alexander Konnopka
- Institute of Health Economics and Health Services Research, UKE, Germany
| | - Holger Schulz
- Department of Medical Psychology, UKE, Hamburg, Germany
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Henwood BF, Kuhn R, Gonzalez AL, Chien J, Tu Y, Bluthenthal R, Cousineau M, Padwa H, Ijadi-Maghsoodi R, Chinchilla M, Smith BT, Gelberg L. Placement into Scattered-Site or Place-Based Permanent Supportive Housing in Los Angeles County, CA, During the COVID-19 Pandemic. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:805-817. [PMID: 38483751 PMCID: PMC11379792 DOI: 10.1007/s10488-024-01359-1] [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] [Accepted: 02/17/2024] [Indexed: 09/08/2024]
Abstract
There are two dominant approaches to implementing permanent supportive housing (PSH), namely place-based (PB) and scattered-site (SS). Formal guidance does not distinguish between these two models and only specifies that PSH should be reserved for those who are most vulnerable with complex health needs. To consider both system- and self-selection factors that may affect housing assignment, this study applied the Gelberg-Anderson behavioral model for vulnerable populations to compare predisposing, enabling, and need factors among people experiencing homelessness (PE) by whether they were assigned to PB-PSH (n = 272) or SS-PSH (n = 185) in Los Angeles County during the COVID-19 pandemic. This exploratory, observational study also included those who were approved but did not receive PSH (n = 94). Results show that there are notable differences between (a) those who received PSH versus those who did not, and (b) those in PB-PSH versus SS-PSH. Specifically, PEH who received PSH were more likely to be white, US-born, have any physical health condition, and have lower health activation scores. PEH who received PB- versus SS-PSH were more likely to be older, Black, have any alcohol use disorder, and have higher health activation scores. These findings suggest that homeless service systems may consider PB-PSH more appropriate for PEH with higher needs but also raises important questions about how race may be a factor in the type of PSH that PEH receive and whether PSH is received at all.
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Affiliation(s)
- Benjamin F Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California (USC), 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA.
| | - Randall Kuhn
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Amanda Landrian Gonzalez
- Suzanne Dworak-Peck School of Social Work, University of Southern California (USC), 669 W. 34th Street, Montgomery Ross Fisher Building, Los Angeles, CA, 90089, USA
| | - Jessie Chien
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Yue Tu
- Department of Population and Public Health Sciences, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ricky Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Michael Cousineau
- Department of Population and Public Health Sciences, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Howard Padwa
- Semel Institute of Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Roya Ijadi-Maghsoodi
- Semel Institute of Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Melissa Chinchilla
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- VA Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Bikki Tran Smith
- Department of Biomedical & Health Sciences, University of Vermont, Burlington, VT, USA
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Department of Health Policy & Management, Fielding School of Public Health, UCLA, Los Angeles, CA, USA
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Savaglio M, Vincent A, Merklin N, Skouteris H. A non-randomised controlled trial of a community-based accommodation and psychosocial support programme for adults experiencing mental illness and homelessness. Aust N Z J Psychiatry 2024:48674241270996. [PMID: 39152551 DOI: 10.1177/00048674241270996] [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] [Indexed: 08/19/2024]
Abstract
BACKGROUND The transition out of inpatient mental health is a crucial time for adults experiencing concurrent mental illness and homelessness, yet evidence regarding effective support options is mixed. Choices is an intensive 3-month psychosocial outreach and crisis accommodation support programme for adults experiencing mental illness and homelessness, delivered by Baptcare in Tasmania, Australia. This study examined the effect of Choices on adults' psychosocial functioning, clinical symptomology and psychiatric readmissions in comparison to standard care only. METHOD Participants were adults aged 18-64 years experiencing mental illness and homelessness, recruited upon discharge from a psychiatric admission. Intervention participants (n = 124) received the Choices programme. Control participants (n = 122) received standard care, clinical assessment and treatment from hospital-based Mental Health Services. Outcomes were psychosocial functioning (primary), clinical symptomology, hospital readmission rate and readmission length of stay. Outcomes were assessed at programme commencement and closure (3 months) and 3 months post-closure (intervention group only). Analysis of covariance was used to analyse differences between groups at closure, while controlling for baseline differences. RESULTS Intervention participants had significantly improved social functioning (encompassing living conditions, social relationships, self-esteem/confidence), overall psychosocial functioning, symptoms of depression and anxiety and shorter hospital readmission length of stay in comparison to the control group. Intervention participants experienced further improvements in social and overall psychosocial functioning 3 months post-closure. CONCLUSION The Choices programme is effective in enhancing the psychosocial functioning of adults experiencing concurrent mental illness and homelessness. These findings support the ongoing delivery of this combined accommodation and wrap-around psychosocial model of intensive support.
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Affiliation(s)
- Melissa Savaglio
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | | | - Helen Skouteris
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Warwick Business School, The University of Warwick, Coventry, UK
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Samosh J, Agha A, Pettey D, Sylvestre J, Aubry T. Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers. Prof Case Manag 2024; 29:139-148. [PMID: 38037223 DOI: 10.1097/ncm.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF STUDY This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction. PRIMARY PRACTICE SETTING The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction. METHODOLOGY AND SAMPLE Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis. RESULTS Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.
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Affiliation(s)
- Jonathan Samosh
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Ayda Agha
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Donna Pettey
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - John Sylvestre
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Tim Aubry
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
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Marcus ER, Carreras Tartak JA, Halasz H, Chen D, Lee J, He S. Discharge process for patients experiencing homelessness in the emergency department: A thematic qualitative study. PLoS One 2024; 19:e0304865. [PMID: 38848410 PMCID: PMC11161068 DOI: 10.1371/journal.pone.0304865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/20/2024] [Indexed: 06/09/2024] Open
Abstract
People experiencing homelessness are more likely to utilize emergency departments than their non-homeless counterparts. However, obtaining a bed in a homeless shelter for patients can be complex. To better understand the challenges of finding a safe discharge plan for homeless patients in the emergency department, our team conducted interviews with emergency department social workers and homeless shelter case managers in the Boston area. We identified and mapped the stages in the processes performed by both parties, identifying challenges with successful placement into a shelter. Furthermore, we assembled a data dictionary of key factors considered when assessing a patient's fit for a homeless shelter. By identifying bottlenecks and areas of opportunity, this study serves as a first step in enabling homeless individuals to receive the post-discharge assistance they require.
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Affiliation(s)
- Elle R. Marcus
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jossie A. Carreras Tartak
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Helena Halasz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ, United States of America
| | - David Chen
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jarone Lee
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Shuhan He
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
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Fleury MJ, Armoon B. Profiles of Permanent Supportive Housing Residents Related to Their Housing Conditions, Service Use, and Associated Sociodemographic and Clinical Characteristics. Psychiatr Q 2024; 95:203-219. [PMID: 38584240 DOI: 10.1007/s11126-024-10071-0] [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] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
As permanent supportive housing (PSH) is the main strategy promoted to reduce homelessness, understanding how PSH resident profiles may be differentiated is crucial to the optimization of PSH implementation - and a subject that hasn't been studied yet. This study identified PSH resident profiles based on their housing conditions and service use, associated with their sociodemographic and clinical characteristics. In 2020-2021, 308 PSH residents from Quebec (Canada) were interviewed, with K-means cluster analysis produced to identify profiles and subsequent analyses to compare profiles and PSH resident characteristics. Of the three profiles identified, Profiles 1 and 2 (70% of sample) showed moderate or poor housing, neighborhood, and health conditions, and moderate or high unmet care needs and service use. Besides their "moderate" conditions, Profile 1 residents (52%) reported being in PSH for more than two years and being less educated. With the "worst" conditions and high service use, Profile 2 (18%) included younger individuals, while Profile 3 (30%) showed the "best" conditions and integrated individuals with more protective determinants (e.g., few in foster care, homelessness at older age, more self-esteem), with a majority living in single-site PSH and reporting higher satisfaction with support and community-based services. Profiles 1 and 2 may be provided with more psychosocial, crisis, harm reduction, and empowerment interventions, and peer helper support. Profile 2 may benefit from more intensive and integrated care, and better housing conditions. Continuous PSH may be sustained for Profile 3, with regular monitoring of service satisfaction and met needs.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
- Douglas Hospital Research Centre, Montréal, Québec, Canada.
| | - Bahram Armoon
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
- Douglas Hospital Research Centre, Montréal, Québec, Canada
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Armoon B, Grenier G, Fleury MJ. Perceived Higher Unmet Care Needs among Adults in Permanent Supportive Housing. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024:10.1007/s10488-024-01390-2. [PMID: 38819494 DOI: 10.1007/s10488-024-01390-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
This study is original in that it assesses various types of care needs, barriers to care, and factors associated with higher unmet needs among 308 permanent supportive housing (PSH) residents in Quebec (Canada). Data from structured interviews that featured the Perceived Need for Care Questionnaire were collected from 2020 to 2022, controlling for the COVID-19 pandemic period. Eight types of care (e.g., information, counseling) were accounted for. Based on the Behavioral Model for Vulnerable Populations, predisposing, need, and enabling factors associated with higher unmet care needs were assessed using a negative binomial regression model. The study found that 56% of adult PSH residents, even those who had lived in PSH for 5 + years, had unmet care needs. Twice as many unmet needs were due to structural (e.g., care access) rather than motivational barriers. Living in single-site PSH, in healthier neighborhoods, having better quality of life and self-esteem, and being more satisfied with housing and outpatient care were associated with fewer unmet care needs. PSH residents with co-occurring mental disorders (MD) and substance use disorders (SUD), and with moderate or severe psychological distress were likely to have more unmet needs. Better access to care, counseling and integrated treatment for co-occurring MD-SUD might be improved, as well as access to information on user rights, health and available support. Welfare benefits could be increased, with more peer support and meaningful activities, especially in single-site PSH. The quality of the neighborhoods where PSH are located might also be better monitored.
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Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Montréal, Québec, Canada
| | - Marie-Josée Fleury
- Douglas Hospital Research Centre, Montréal, Québec, Canada.
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
- Douglas Mental Health University Institute, Research Centre, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada.
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Anderson J, Trevella C, Burn AM. Interventions to improve the mental health of women experiencing homelessness: A systematic review of the literature. PLoS One 2024; 19:e0297865. [PMID: 38568910 PMCID: PMC10990227 DOI: 10.1371/journal.pone.0297865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/10/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Homelessness is a growing public health challenge in the United Kingdom and internationally, with major consequences for physical and mental health. Women represent a particularly vulnerable subgroup of the homeless population, with some evidence suggesting that they suffer worse mental health outcomes than their male counterparts. Interventions aimed at improving the lives of homeless women have the potential to enhance mental health and reduce the burden of mental illness in this population. This review synthesised the evidence on the effectiveness and acceptability of interventions which aim to improve mental health outcomes in homeless women. METHODS Five electronic bibliographic databases: MEDLINE, PsycInfo, CINAHL, ASSIA and EMBASE, were searched. Studies were included if they measured the effectiveness or acceptability of any intervention in improving mental health outcomes in homeless women. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. A narrative summary of the study findings in relation to the research questions was produced. RESULTS Thirty-nine studies met inclusion criteria. Overall, there was moderate evidence of the effectiveness of interventions in improving mental health outcomes in homeless women, both immediately post-intervention and at later follow-up. The strongest evidence was for the effectiveness of psychotherapy interventions. There was also evidence that homeless women find interventions aimed at improving mental health outcomes acceptable and helpful. CONCLUSIONS Heterogeneity in intervention and study methodology limits the ability to draw definitive conclusions about the extent to which different categories of intervention improve mental health outcomes in homeless women. Future research should focus on lesser-studied intervention categories, subgroups of homeless women and mental health outcomes. More in-depth qualitative research of factors that enhance or diminish the acceptability of mental health interventions to homeless women is also required.
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Affiliation(s)
- Joanna Anderson
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Charlotte Trevella
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Anne-Marie Burn
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
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Armoon B, L'Espérance N, Fleury MJ. Variables Associated with Quality of Life Among Individuals Living in Permanent Supportive Housing. Community Ment Health J 2024; 60:259-271. [PMID: 37462796 DOI: 10.1007/s10597-023-01167-1] [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] [Received: 05/08/2023] [Accepted: 07/05/2023] [Indexed: 01/28/2024]
Abstract
This study identified individual sociodemographic and clinical characteristics and service use patterns associated with quality of life (QoL) among 308 individuals living in permanent supportive housing (PSH) in Québec (Canada). Data were collected between 2020 and 2022, and linear multivariate analyses produced. Results demonstrated that better individual psychosocial conditions were positively associated with higher QoL. As well, living in PSH located in good neighborhoods for at least 5 years, higher self-esteem and community integration were positively associated with greater QoL. Met needs, satisfaction with housing support services, and no use of acute care were also linked with positive QoL. Comprehensive efforts to improve treatment for mental health disabilities responsive to the needs of PSH residents, and sustained long-term housing may reinforce QoL. Encouraging active participation in community-based activities, incorporating biophilic design into the neighborhoods around PSH, and promoting satisfaction with care may also enhance QoL.
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Affiliation(s)
- Bahram Armoon
- Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Québec, Canada
| | - Marie-Josée Fleury
- Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada.
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
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Toro PA, Turner TN, Szarzyńska ME. Building Resilience through Intervention, Direct Guidance, and Empowerment (BRIDGE): A demonstration project to assist youth aging out of foster care in Poland. J Prev Interv Community 2024; 52:11-34. [PMID: 38385309 DOI: 10.1080/10852352.2024.2317662] [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: 02/23/2024]
Abstract
Building Resilience through Intervention, Direct Guidance, and Empowerment (BRIDGE) is an innovative program designed to prevent homelessness and other negative outcomes among youth aging out of foster care. BRIDGE was pilot-tested on youth aging out of two orphanages in a city in southern Poland in 2009-2012. Youth were recruited at age 17, before aging out at age 18. Quasi-experimental methods were used to evaluate program outcomes among nine BRIDGE clients compared to two matched groups (n = 9 and n = 18) of youth who had recently aged out of orphanages in the same Polish region. Consistent with Hypothesis 1, results of chi-square tests showed that, over an 18-month follow-up period, BRIDGE clients experienced superior housing outcomes relative to both matched groups. Consistent with Hypothesis 2, the results of a between-subjects ANOVA showed that BRIDGE clients received significantly greater income relative to the matched groups. Within-subjects effects of BRIDGE from baseline across 6-, 12-, and 18-month follow-ups were examined with repeated-measures ANOVAs. Consistent with Hypotheses 3-5, results showed that across time BRIDGE clients experienced a general increase in income and decrease in psychological distress (i.e., total distress, obsessive-compulsiveness, interpersonal sensitivity, and paranoia). The study's findings support the further development of BRIDGE and similar programs.
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Affiliation(s)
- Paul A Toro
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
| | - Tia N Turner
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
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Marshall CA, Phillips B, Holmes J, Todd E, Hill R, Panter G, Easton C, Landry T, Collins S, Greening T, O’Brien A, Jastak M, Ridge R, Goldszmidt R, Shanoff C, Laliberte Rudman D, Carlsson A, Aryobi S, Szlapinski J, Carrillo-Beck R, Pacheco N, Perez S, Oudshoorn A. "I can't remember the last time I was comfortable about being home": lived experience perspectives on thriving following homelessness. Int J Qual Stud Health Well-being 2023; 18:2176979. [PMID: 36803094 PMCID: PMC9946331 DOI: 10.1080/17482631.2023.2176979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 02/01/2023] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Strategies for preventing and ending homelessness are frequently measured by their effectiveness on indices of tenancy sustainment. To shift this narrative, we conducted research to identify what is needed to "thrive" following homelessness from the perspectives of persons with lived experience in Ontario, Canada. METHODS Conducted in the context of a community-based participatory research study aimed at informing the development of intervention strategies, we interviewed 46 persons living with mental illness and/or substance use disorder [n = 25 (54.3%) unhoused; n = 21 (45.7%) housed following homelessness] using qualitative interviews. A subsample of 14 participants agreed to engage in photovoice interviews. We analysed these data abductively using thematic analysis informed by health equity and social justice. RESULTS Participants described experiences of "living in a state of lack" following homelessness. This essence was expressed through four themes: 1) housing as part one of the journey to home; 2) finding and keeping "my people"; 3) meaningful activity as critical for thriving following homelessness; and 4) struggling to access mental health supports in the context of challenging circumstances. CONCLUSIONS Individuals struggle to thrive following homelessness in the context of insufficient resources. There is a need to build on existing interventions to address outcomes beyond tenancy sustainment.
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Affiliation(s)
- Carrie Anne Marshall
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Brooke Phillips
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Julia Holmes
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Eric Todd
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - River Hill
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
- Providence Care Hospital, Kingston, Canada
- Salvation Army London Centre of Hope, London, Canada
- Home Base Housing, Kingston, Canada
- Trellis HIV and Community Care, Kingston, Canada
- Addiction and Mental Health Services Kingston, Frontenac, Lennox & Addington (KFLA), Kingston, Canada
- School of Occupational Therapy, Western University, London, Canada
- School of Nursing, Western University, London, Canada
| | - George Panter
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Corinna Easton
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | | | - Sarah Collins
- Salvation Army London Centre of Hope, London, Canada
| | | | | | - Marlo Jastak
- Addiction and Mental Health Services Kingston, Frontenac, Lennox & Addington (KFLA), Kingston, Canada
| | | | - Rebecca Goldszmidt
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Chelsea Shanoff
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | | | | | - Suliman Aryobi
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Jessica Szlapinski
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Rozelen Carrillo-Beck
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Nicole Pacheco
- Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Canada
| | - Shauna Perez
- Addiction and Mental Health Services Kingston, Frontenac, Lennox & Addington (KFLA), Kingston, Canada
| | - Abe Oudshoorn
- School of Nursing, Western University, London, Canada
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Shade K, Hidalgo P, Arteaga M, Rowland J, Huang W. Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project. Prof Case Manag 2023; 28:271-279. [PMID: 37787704 DOI: 10.1097/ncm.0000000000000645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE OF STUDY Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission. PRIMARY PRACTICE SETTING The setting was a vertically integrated health care system located in Northern California. METHODOLOGY AND SAMPLE This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings. RESULTS Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).
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Affiliation(s)
- Kate Shade
- Kate Shade, PhD, RN , is an assistant professor at Cal State East Bay and an adjunct associate professor at Samuel Merritt University. Dr. Shade has experience in public health case management and program evaluation. She has conducted research with youth involved in the juvenile justice system
- Paulina Hidalgo, MSN, RN , is a nurse case manager at Stanford Healthcare and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Manuel Arteaga, MSN, RN , is a pediatric nurse case manager at UCSF/Benioff Children's Hospitals and serves on the board of a federally qualified health center in the San Francisco Bay Area. Mr. Arteaga has experience as a case manager with the department of child support services and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Janet Rowland, EdD, MSN, RN-BC, ACM-RN , is the assistant director of the case management program and an assistant professor at Samuel Merritt University. She holds certifications in case management from the ANCC and the ACMA. She has worked for over 25 years in care coordination and public health nursing and previously served in the US Army Nurse Corps
- Winnie Huang, MSN, RN, PHN , is currently working as an RN case manager at Northern California outside utilization review services with Kaiser Permanente. She has experience in clinical case management including leadership and education roles in various organizations
| | - Paulina Hidalgo
- Kate Shade, PhD, RN , is an assistant professor at Cal State East Bay and an adjunct associate professor at Samuel Merritt University. Dr. Shade has experience in public health case management and program evaluation. She has conducted research with youth involved in the juvenile justice system
- Paulina Hidalgo, MSN, RN , is a nurse case manager at Stanford Healthcare and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Manuel Arteaga, MSN, RN , is a pediatric nurse case manager at UCSF/Benioff Children's Hospitals and serves on the board of a federally qualified health center in the San Francisco Bay Area. Mr. Arteaga has experience as a case manager with the department of child support services and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Janet Rowland, EdD, MSN, RN-BC, ACM-RN , is the assistant director of the case management program and an assistant professor at Samuel Merritt University. She holds certifications in case management from the ANCC and the ACMA. She has worked for over 25 years in care coordination and public health nursing and previously served in the US Army Nurse Corps
- Winnie Huang, MSN, RN, PHN , is currently working as an RN case manager at Northern California outside utilization review services with Kaiser Permanente. She has experience in clinical case management including leadership and education roles in various organizations
| | - Manuel Arteaga
- Kate Shade, PhD, RN , is an assistant professor at Cal State East Bay and an adjunct associate professor at Samuel Merritt University. Dr. Shade has experience in public health case management and program evaluation. She has conducted research with youth involved in the juvenile justice system
- Paulina Hidalgo, MSN, RN , is a nurse case manager at Stanford Healthcare and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Manuel Arteaga, MSN, RN , is a pediatric nurse case manager at UCSF/Benioff Children's Hospitals and serves on the board of a federally qualified health center in the San Francisco Bay Area. Mr. Arteaga has experience as a case manager with the department of child support services and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Janet Rowland, EdD, MSN, RN-BC, ACM-RN , is the assistant director of the case management program and an assistant professor at Samuel Merritt University. She holds certifications in case management from the ANCC and the ACMA. She has worked for over 25 years in care coordination and public health nursing and previously served in the US Army Nurse Corps
- Winnie Huang, MSN, RN, PHN , is currently working as an RN case manager at Northern California outside utilization review services with Kaiser Permanente. She has experience in clinical case management including leadership and education roles in various organizations
| | - Janet Rowland
- Kate Shade, PhD, RN , is an assistant professor at Cal State East Bay and an adjunct associate professor at Samuel Merritt University. Dr. Shade has experience in public health case management and program evaluation. She has conducted research with youth involved in the juvenile justice system
- Paulina Hidalgo, MSN, RN , is a nurse case manager at Stanford Healthcare and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Manuel Arteaga, MSN, RN , is a pediatric nurse case manager at UCSF/Benioff Children's Hospitals and serves on the board of a federally qualified health center in the San Francisco Bay Area. Mr. Arteaga has experience as a case manager with the department of child support services and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Janet Rowland, EdD, MSN, RN-BC, ACM-RN , is the assistant director of the case management program and an assistant professor at Samuel Merritt University. She holds certifications in case management from the ANCC and the ACMA. She has worked for over 25 years in care coordination and public health nursing and previously served in the US Army Nurse Corps
- Winnie Huang, MSN, RN, PHN , is currently working as an RN case manager at Northern California outside utilization review services with Kaiser Permanente. She has experience in clinical case management including leadership and education roles in various organizations
| | - Winnie Huang
- Kate Shade, PhD, RN , is an assistant professor at Cal State East Bay and an adjunct associate professor at Samuel Merritt University. Dr. Shade has experience in public health case management and program evaluation. She has conducted research with youth involved in the juvenile justice system
- Paulina Hidalgo, MSN, RN , is a nurse case manager at Stanford Healthcare and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Manuel Arteaga, MSN, RN , is a pediatric nurse case manager at UCSF/Benioff Children's Hospitals and serves on the board of a federally qualified health center in the San Francisco Bay Area. Mr. Arteaga has experience as a case manager with the department of child support services and graduated with a master of science in nursing, case management from Samuel Merritt University in December 2021
- Janet Rowland, EdD, MSN, RN-BC, ACM-RN , is the assistant director of the case management program and an assistant professor at Samuel Merritt University. She holds certifications in case management from the ANCC and the ACMA. She has worked for over 25 years in care coordination and public health nursing and previously served in the US Army Nurse Corps
- Winnie Huang, MSN, RN, PHN , is currently working as an RN case manager at Northern California outside utilization review services with Kaiser Permanente. She has experience in clinical case management including leadership and education roles in various organizations
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Noland DH, Morris CD, Kayser AM, Garver-Apgar CE. Results of a Peer Navigator Program to Address Chronic Illness Among Persons Experiencing Homelessness. J Community Health 2023; 48:606-615. [PMID: 36802004 DOI: 10.1007/s10900-023-01194-9] [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] [Accepted: 01/22/2023] [Indexed: 02/23/2023]
Abstract
People who are homeless disproportionately experience the burdens of chronic disease, have limited access to preventive care, and may be less trusting of healthcare agencies. The Collective Impact Project created and evaluated an innovative model designed to increase chronic disease screening and referral to healthcare and public health services. Trained Peer Navigators (PNs), who were paid staff with lived experiences similar to the clients served, were embedded in five agencies serving people experiencing homelessness or at risk for homelessness. Over two years, PNs engaged 1071 individuals. Of those, 823 were screened for chronic diseases and 429 were referred to healthcare services. Alongside screening and referrals, the project demonstrated the value of convening a coalition of community stakeholders, experts, and resources to identify service gaps and how PN functions might complement existing staffing roles. Project findings add to a growing literature documenting unique PN roles that potentially reduce health inequities.
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Affiliation(s)
- Derek H Noland
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, MS F478, 1890 N Revere Ct, Aurora, CO, 80045, USA.
| | - Chad D Morris
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, MS F478, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Ashley M Kayser
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, MS F478, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Christine E Garver-Apgar
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, MS F478, 1890 N Revere Ct, Aurora, CO, 80045, USA
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Duncan A, Kirst M, Dainty KN, Wodchis WP, Stergiopoulos V. Case managers' reflections of a brief case management intervention in Canada. Front Psychiatry 2023; 14:1151904. [PMID: 37448491 PMCID: PMC10336220 DOI: 10.3389/fpsyt.2023.1151904] [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: 01/26/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM). Objective This study sought to explore case managers' perspectives and experiences with this new service delivery model. Methods Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis. Results Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention. Conclusion The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.
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Affiliation(s)
- Andrea Duncan
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Maritt Kirst
- Community Psychology, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Weightman AL, Kelson MJ, Thomas I, Mann MK, Searchfield L, Willis S, Hannigan B, Smith RJ, Cordiner R. Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1329. [PMID: 37206622 PMCID: PMC10189499 DOI: 10.1002/cl2.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority. Objectives To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact. Search Methods We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies. Selection Criteria We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation. Data Collection and Analysis We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data. Main Results We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings. Case Management and Housing Outcomes Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches. Case Management and Mental Health Outcomes The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817). Case Management and Other Outcomes Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment. Case Management Components For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services. Characteristics of Persons Experiencing Homelessness No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3. The Broader Context of Delivery of Case Management Programmes Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice. Cost Effectiveness The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed. Authors' Conclusions Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.
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Affiliation(s)
| | - Mark J. Kelson
- Department of Mathematics and Statistics, Faculty of Environment, Science and EconomyUniversity of ExeterExeterUK
| | - Ian Thomas
- Wales Institute of Social and Economic Research and Data (WISERD)Cardiff UniversityCardiffUK
| | - Mala K. Mann
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Lydia Searchfield
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Simone Willis
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Ben Hannigan
- Mental Health Nursing, School of Healthcare SciencesCardiff UniversityCardiffUK
| | | | - Rhiannon Cordiner
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
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Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C, Cordasco K, Basu A, Page T, Mahmood R, Motala A, Barnard J, Wong M, Fu N, Miake-Lye IM. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open 2023; 13:e060232. [PMID: 37197809 DOI: 10.1136/bmjopen-2021-060232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVE For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.
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Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - David Ganz
- Geriatrics Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
| | - Sonali Saluja
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California, USA
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Timothy Kim
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolyn Turvey
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City, Iowa, USA
- Rural Health Resource Center, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
| | - Kristina Cordasco
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aashna Basu
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
- Care in the Community Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Tonya Page
- Office of Community, Clinical Integration & Field Support, Veteran Affairs Central Office, Kentucky City, Kentucky, USA
| | - Reshma Mahmood
- Santa Maria and San Luis Obispo Community Outpatient Clinics, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Jenny Barnard
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michelle Wong
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ning Fu
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
- School of Public Administration and Emergency Management, Jinan University, Guangzhou, Guangdong, China
| | - Isomi M Miake-Lye
- VA West Los Angeles Evidence-based Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Gabrielian S, Cordasco KM, Finley EP, Hoffmann LC, Harris T, Calderon RA, Barnard JM, Ganz DA, Olmos-Ochoa TT. Engaging stakeholders to inform national implementation of critical time intervention in a program serving homeless-experienced Veterans. Front Psychol 2022; 13:1009467. [PMID: 36591052 PMCID: PMC9795188 DOI: 10.3389/fpsyg.2022.1009467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 12/15/2022] Open
Abstract
The Veterans Affairs (VA) Grant and Per Diem Case Management "Aftercare" program provides 6 months of case management for homeless-experienced Veterans (HEVs) transitioning to permanent housing, with the aim of decreasing returns to homelessness. Implementing Critical Time Intervention (CTI)-an evidence-based case management practice-would standardize care across the 128 community-based agencies that provide Aftercare services. To prepare for national CTI implementation in Aftercare, guided by Replicating Effective Programs (REP), we conducted a four-site pilot in which we adapted a CTI implementation package (training, technical assistance, and external facilitation); characterized stakeholder perspectives regarding the acceptability and appropriateness of this package; and identified contextual factors that affected CTI implementation. We engaged a stakeholder workgroup to tailor existing CTI training and technical assistance materials for Aftercare. To provide tailored support for providers and leaders to adopt and incorporate evidence-based practices (EBPs) into routine care, we also developed external facilitation materials and processes. Over 9 months, we implemented this package at four sites. We conducted semi-structured interviews at pre-implementation, mid-implementation, and 6 months post-implementation, with HEVs (n = 37), case managers (n = 16), supervisors (n = 10), and VA leaders (n = 4); these data were integrated with templated reflection notes from the project facilitator. We used rapid qualitative analysis and targeted coding to assess the acceptability and appropriateness of CTI and our implementation package and identify factors influencing CTI implementation. Stakeholders generally found CTI acceptable and appropriate; there was consensus that components of CTI were useful and compatible for this setting. To adapt our implementation package for scale-up, this pilot highlighted the value of robust and tangible CTI training and technical assistance-grounded in real-world cases-that highlights the congruence of CTI with relevant performance metrics. Variations in agency-level contextual factors may necessitate more intense and tailored supports to implement and sustain complex EBPs like CTI. Processes used in this pilot are relevant for implementing other EBPs in organizations that serve vulnerable populations. EBP scale-up and sustainment can be enhanced by engaging stakeholders to tailor EBPs for specific contexts; pilot testing and refining implementation packages for scale-up; and using qualitative methods to characterize contextual factors that affect EBP implementation.
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Affiliation(s)
- Sonya Gabrielian
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Greater Los Angeles, Los Angeles, CA, United States
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kristina M. Cordasco
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Erin P. Finley
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Division of Hospital Medicine, Department of Medicine and Department of Psychiatry, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Lauren C. Hoffmann
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Greater Los Angeles, Los Angeles, CA, United States
| | - Taylor Harris
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Greater Los Angeles, Los Angeles, CA, United States
| | - Ronald A. Calderon
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Greater Los Angeles, Los Angeles, CA, United States
| | - Jenny M. Barnard
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - David A. Ganz
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Greater Los Angeles Geriatric Research, Education, and Clinical Center (GRECC), VA Greater Los Angeles, Los Angeles, CA, United States
| | - Tanya T. Olmos-Ochoa
- Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, United States
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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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Roebuck M, Latimer E, Bergeron-Leclerc C, Briand C, Durbin J, Goscha R, Krupa T, Setliff A, Vallée C, Aubry T. The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes. Psychiatr Serv 2022; 73:1248-1254. [PMID: 35502516 DOI: 10.1176/appi.ps.202100387] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to examine how the client–case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients’ quality of life, hope, and community functioning. METHODS In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client–case manager working alliance and clients’ quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models. RESULTS Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months). CONCLUSIONS The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.
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Affiliation(s)
- Maryann Roebuck
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Eric Latimer
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Christiane Bergeron-Leclerc
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Catherine Briand
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Janet Durbin
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Rick Goscha
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Terry Krupa
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Alissa Setliff
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Catherine Vallée
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
| | - Tim Aubry
- School of Psychology, University of Ottawa, Ottawa (Roebuck, Aubry); Douglas Mental Health University Institute and McGill University, Montreal (Latimer); Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Chicoutimi, Saguenay, Quebec (Bergeron-Leclerc); Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, and Research Centre of Montreal Mental Health University Institute, Montreal, Quebec (Briand); Centre for Addictions and Mental Health and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto (Durbin); California Institute for Behavioral Solutions, Sacramento (Goscha); School of Rehabilitation Therapy, Queen's University, Kingston, Ontario (Krupa); Eastern Health, St. John's, Newfoundland and Labrador (Setliff); Faculté de médecine, Université Laval, Quebec City, Quebec (Vallée)
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Marshall CA, Boland L, Westover LA, Goldszmidt R, Bengall J, Aryobi S, Isard R, Easton C, Gewurtz R. Effectiveness of employment-based interventions for persons experiencing homelessness: A systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2142-2169. [PMID: 35748222 DOI: 10.1111/hsc.13892] [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: 03/01/2022] [Revised: 05/26/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Employment is frequently desired by persons who experience homelessness yet is often elusive. Little is known about the range and effectiveness of employment-based interventions evaluated in existing literature on key psychosocial outcomes including employment participation, mental well-being, housing tenure, community integration and substance use. To identify and synthesise existing studies, we conducted a systematic review of effectiveness using the methodology proposed by the Joanna Briggs Institute (JBI) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Following the removal of duplicates, we screened 13,398 titles and abstracts, and reviewed 79 studies at the full-text review stage using two independent raters. A total of 16 studies met criteria for inclusion in a narrative synthesis and were subjected to critical appraisal. The majority of studies were conducted in the US (n = 14; 87.5%) with other studies published in Canada (n = 1; 6.3%) and Australia (n = 1; 6.3%). Interventions evaluated in existing studies included combined substance use and vocational skills interventions (n = 7; 43.8%), supported employment (n = 6; 37.5%), and integrated supports including an employment component (n = 3; 18.8%). The effectiveness of these interventions on employment, mental well-being, housing tenure, community integration, and substance use is presented. Findings suggest that research evaluating employment interventions for persons who experience homelessness is in an early stage of development. Researchers and practitioners may consider collaborating with persons with lived experiences of homelessness and practitioners in co-designing and modifying existing approaches to target key outcomes more effectively. Policymakers may consider allocating resources to such initiatives to further the development of practice and research aimed at supporting persons who experience homelessness to secure and sustain employment during and following homelessness.
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Affiliation(s)
- Carrie Anne Marshall
- Social Justice in Mental Health Research Lab, Faculty of Health Sciences, School of Occupational Therapy, Western University, London, Ontario, Canada
| | - Leonie Boland
- Faculty of Health and Human Sciences, Occupational Therapy, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - Lee Ann Westover
- Teacher's College, Columbia University, New York City, New York, USA
| | - Rebecca Goldszmidt
- Social Justice in Mental Health Research Lab, Faculty of Health Sciences, School of Occupational Therapy, Western University, London, Ontario, Canada
| | - Jordana Bengall
- Social Justice in Mental Health Research Lab, Faculty of Health Sciences, School of Occupational Therapy, Western University, London, Ontario, Canada
| | - Suliman Aryobi
- Social Justice in Mental Health Research Lab, Faculty of Health Sciences, School of Occupational Therapy, Western University, London, Ontario, Canada
| | - Roxanne Isard
- Disciplinary Coordinator for the Faculty of Information & Media Studies & the Faculty of Education, Allyn & Betty Taylor Library, Western University, London, Ontario, Canada
| | - Corinna Easton
- Social Justice in Mental Health Research Lab, Faculty of Health Sciences, School of Occupational Therapy, Western University, London, Ontario, Canada
| | - Rebecca Gewurtz
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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Bell L, Whelan M, Fernandez E, Lycett D. Nurse-led mental and physical healthcare for the homeless community: A qualitative evaluation. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2282-2291. [PMID: 35266231 PMCID: PMC10078647 DOI: 10.1111/hsc.13778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/19/2022] [Accepted: 02/27/2022] [Indexed: 05/05/2023]
Abstract
Increased morbidity and mortality rates are prominent issues among homeless individuals. To help reduce these health inequalities, dedicated senior mental and physical health nurses have been deployed to work within and alongside local statutory and voluntary organisations. This qualitative evaluation examined the impact of nurse-led homeless healthcare in Warwickshire, United Kingdom. During January and February 2021, online semi-structured interviews were conducted with 17 professionals including the mental and physical homeless health nurses (n = 4), statutory health and local authority professionals (n = 4), and voluntary and community sector professionals (n = 9). Interviews were qualitatively analysed using inductive, reflexive thematic analysis. Data analysis identified three overarching themes related to the meaning, impact and future development of nurse-led homeless healthcare: (1) Nurse-led homeless healthcare and health inequalities, (2) The multi-agency approach of nurse-led homeless healthcare, and (3) Future development of nurse-led homeless healthcare. The findings confirm the benefits of homeless healthcare in reducing health inequalities and promoting a more accessible, flexible and person-centred approach to holistic care. Yet, prevailing organisational and system-level barriers were also identified as currently limiting the capacity, provision and practicalities of delivering nurse-led homeless healthcare. Recommendations were identified with international relevance and included: (i) continued implementation of person-centred healthcare for homeless individuals, (ii) strengthening of organisational collaboration and communication pathways to improve coordinated care, (iii) development of the managerial and structural aspects of provision, (iv) addressing limitations associated with scope and capacity to ensure that delivered healthcare is adequately intensive, (v) increased availability of clinical or therapeutic spaces, and (vi) implementation of long-term plans supported by evaluation and commissioning.
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Affiliation(s)
- Lauren Bell
- Centre for Intelligent HealthcareCoventry UniversityCoventryUK
| | - Maxine Whelan
- Centre for Intelligent HealthcareCoventry UniversityCoventryUK
| | | | - Deborah Lycett
- Centre for Intelligent HealthcareCoventry UniversityCoventryUK
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22
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Comparing two implementation strategies for implementing and sustaining a case management practice serving homeless-experienced veterans: a protocol for a type 3 hybrid cluster-randomized trial. Implement Sci 2022; 17:67. [PMID: 36192785 PMCID: PMC9527738 DOI: 10.1186/s13012-022-01236-1] [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: 07/11/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background The Veterans Health Administration (VA) Grant and Per Diem case management “aftercare” program provides 6 months of case management for homeless-experienced veterans (HEVs) undergoing housing transitions. To standardize and improve aftercare services, we will implement critical time intervention (CTI), an evidence-based, structured, and time-limited case management practice. We will use two strategies to support the implementation and sustainment of CTI at 32 aftercare sites, conduct a mixed-methods evaluation of this implementation initiative, and generate a business case analysis and implementation playbook to support the continued spread and sustainment of CTI in aftercare. Methods We will use the Replicating Effective Programs (REP) implementation strategy to support CTI implementation at 32 sites selected by our partners. Half (n=16) of these sites will also receive 9 months of external facilitation (EF, enhanced REP). We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus enhanced REP. We will cluster potential sites into three implementation cohorts staggered in 9-month intervals. Within each cohort, we will use permuted block randomization to balance key site characteristics among sites receiving REP versus enhanced REP; sites will not be blinded to their assigned strategy. We will use mixed methods to assess the impacts of the implementation strategies. As fidelity to CTI influences its effectiveness, fidelity to CTI is our primary outcome, followed by sustainment, quality metrics, and costs. We hypothesize that enhanced REP will have higher costs than REP alone, but will result in stronger CTI fidelity, sustainment, and quality metrics, leading to a business case for enhanced REP. This work will lead to products that will support our partners in spreading and sustaining CTI in aftercare. Discussion Implementing CTI within aftercare holds the potential to enhance HEVs’ housing and health outcomes. Understanding effective strategies to support CTI implementation could assist with a larger CTI roll-out within aftercare and support the implementation of other case management practices within and outside VA. Trial registration This project was registered with ClinicalTrials.gov as “Implementing and sustaining Critical Time Intervention in case management programs for homeless-experienced Veterans.” Trial registration NCT05312229, registered April 4, 2022.
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23
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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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A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness. Community Ment Health J 2022; 58:944-954. [PMID: 34669090 PMCID: PMC8527446 DOI: 10.1007/s10597-021-00903-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/02/2021] [Indexed: 11/07/2022]
Abstract
The purpose of this study was to examine clients' perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers' flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients' preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.
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Khan BM, Reid N, Stergiopoulos V. Advancing recovery education for people experiencing housing instability: A qualitative analysis of service user and provider perspectives in Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:1541-1549. [PMID: 34309106 DOI: 10.1111/hsc.13484] [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: 11/29/2020] [Revised: 05/14/2021] [Accepted: 05/29/2021] [Indexed: 06/13/2023]
Abstract
The recovery paradigm is increasingly being adopted within mental health services internationally, to support a process of personal change for affected individuals, with the aim of living a satisfying, hopeful, contributing life within the limitations of mental illness. In efforts to assist the process of recovery, Recovery Education Centres (REC), offering recovery supports through education rather than traditional service models, have been widely implemented; there is limited evidence to date with respect to the experiences and outcomes of disadvantaged populations, such as people experiencing homelessness, with recovery education. This study used qualitative methods to explore the perspectives and experiences of service users and providers of the Supporting Transitions and Recovery (STAR) Learning Centre in Toronto, Canada, focused on supporting the process of recovery for individuals with histories of homelessness. Between July 2017 and June 2018, semistructured interviews with 20 service users, one key informant, and a focus group comprising eight current and former REC staff and volunteers were conducted to explore opportunities to better tailor the curriculum, and key programmatic features, to the needs of the population. Interviews were analysed using inductive thematic analysis. Most participants described favourable experiences with the REC and suggested adding more challenging course content (n = 10) and increasing delivery options (n = 8), highlighting the diversity of participant needs. Others described the importance of improving accessibility through geographic expansion, offering transit subsidies, and using innovative media. In addition, the importance of delivering more courses in partnership with community partners, to maximise reach and impact, was also highlighted (n = 15). This study underscores the importance of engaging service users and providers, including peers, in ongoing adaptations to best serve the target populations. The expertise and lived experience of these key stakeholders offer a unique lens, supporting the process of recovery, through co-production of curriculum content and joint program planning and improvements. Findings can inform REC development for disadvantaged populations and potentially enhance recovery outcomes for those experiencing multiple barriers to recovery.
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Affiliation(s)
- Bushra M Khan
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Nadine Reid
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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26
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Uphoff EP, Zamperoni V, Yap J, Simmonds R, Rodgers M, Dawson S, Seymour C, Kousoulis A, Churchill R. Mental health promotion and protection relating to key life events and transitions in adulthood: a rapid systematic review of systematic reviews. J Ment Health 2022:1-14. [PMID: 35658814 DOI: 10.1080/09638237.2022.2069724] [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: 12/06/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND During the decades representing working-age adulthood, most people will experience one or several significant life events or transitions. These may present a challenge to mental health. AIM The primary aim of this rapid systematic review of systematic reviews was to summarise available evidence on the effectiveness of interventions to promote and protect mental health relating to four key life events and transitions: pregnancy and early parenthood, bereavement, unemployment, and housing problems. This review was conducted to inform UK national policy on mental health support. METHODS We searched key databases for systematic reviews of interventions for working-age adults (19 to 64 years old) who had experienced or were at risk of experiencing one of four key life events. Titles and abstracts were screened by two reviewers in duplicate, as were full-text manuscripts of relevant records. We assessed the quality of included reviews and extracted data on the characteristics of each literature review. We prioritised high quality, recent systematic reviews for more detailed data extraction and synthesis. RESULTS The search and screening of 3997 titles/abstracts and 239 full-text papers resulted in 134 relevant studies, 68 of which were included in a narrative synthesis. Evidence was strongest and of the highest quality for interventions to support women during pregnancy and after childbirth. For example, we found benefits of physical activity and psychological therapy for outcomes relating to mental health after birth. There was high quality evidence of positive effects of online bereavement interventions and psychological interventions on symptoms of grief, post-traumatic stress, and depression. Evidence was inconclusive and of lower quality for a range of other bereavement interventions, unemployment support interventions, and housing interventions. CONCLUSIONS Whilst evidence based mental health prevention and promotion is available during pregnancy and early parenthood and for bereavement, it is unclear how best to support adults experiencing job loss, unemployment, and housing problems.
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Affiliation(s)
| | | | - Jade Yap
- Mental Health Foundation, London, UK
| | | | - Mark Rodgers
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
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27
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Gottlieb LM, Lindau ST, Peek ME. Why Add "Abolition" to the National Academies of Sciences, Engineering, and Medicine's Social Care Framework? AMA J Ethics 2022; 24:E170-180. [PMID: 35325517 PMCID: PMC9591153 DOI: 10.1001/amajethics.2022.170] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Abundant evidence demonstrates that enduring, endemic racism plays an important role in determining patient health. This commentary reviews a patient case about disease self-management and subsequent health outcomes that are shaped by social and economic circumstances. We analyze the case using a framework for social care developed in 2019 by the National Academies of Sciences, Engineering, and Medicine (NASEM). We then propose that the NASEM framework be adapted by adding the category abolition, which could make the other social care practices transformative for historically marginalized populations.
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Affiliation(s)
- Laura M Gottlieb
- Professor in the Department of Family and Community Medicine at the University of California, San Francisco
| | - Stacy Tessler Lindau
- Professor of obstetrics and gynecology and medicine-geriatrics as well as a practicing gynecologist at the University of Chicago in Illinois
| | - Monica E Peek
- Professor of medicine and the director of research (and associate director) at the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
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28
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Abstract
PURPOSE OF REVIEW We reviewed the existing and recent community models of care in schizophrenia. We examine characteristics, recent updates, evidence, cost-effectiveness, and patients' acceptance for existing and new community-based care models in high-income (HI) and low- and middle-income (LAMI) countries. RECENT FINDINGS Assertive Community Treatment (ACT), Intensive Case Management (ICM), and Crisis Intervention are cost-effective interventions for schizophrenia and time tested in the last few decades in HI countries. The growing evidence suggests that tailor-made ACTs and ICM can effectively reduce substance use, homelessness, and criminal activity in persons with schizophrenia who live in the community. Similarly, in LAMI Countries, a few community-based care models for schizophrenia have been developed and tested based on community-based rehabilitation principles. The modality of a community model of care and interventions for a person with schizophrenia should be chosen based on the person's co-existing psychosocial difficulties and challenges such as homelessness, criminal behaviour, and substance use.
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Affiliation(s)
- Guru S. Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, 560029 India
| | - Mohan K. Isaac
- Clinical Professor of Psychiatry, Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Fremantle Hospital, Fremantle Hospital, Level 7, T Block, Fremantle, WA 6160 Australia
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29
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Weightman AL, Kelson MJ, Thomas I, Mann MK, Searchfield L, Hannigan B, Smith RJ, Willis S, Cordiner R. PROTOCOL: Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis. CAMPBELL SYSTEMATIC REVIEWS 2022; 18:e1220. [PMID: 36908653 PMCID: PMC8866910 DOI: 10.1002/cl2.1220] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This is the protocol for a Campbell review. The objectives are as follows: To carry out a mixed methods review to summarise current evidence relating to the components of case-management interventions for people experiencing homelessness.
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Affiliation(s)
| | - Mark J. Kelson
- Alan Turing Institute, School of MathematicsUniversity of ExeterUK
| | - Ian Thomas
- Wales Institute of Social and Economic Research and Data (WISERD)Cardiff UniversityCardiffUK
| | - Mala K. Mann
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Lydia Searchfield
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Ben Hannigan
- Mental Health Nursing, School of Healthcare SciencesCardiff UniversityCardiffUK
| | | | - Simone Willis
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Rhiannon Cordiner
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
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30
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Garcia-Jorda D, Fabreau GE, Li QKW, Polachek A, Milaney K, McLane P, McBrien KA. Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Serv Res 2022; 22:232. [PMID: 35183174 PMCID: PMC8858447 DOI: 10.1186/s12913-022-07590-6] [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: 10/27/2020] [Accepted: 02/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges.
Methods
We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed.
Results
From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges.
Conclusions
A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.
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31
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Gessl AS, Flörl A, Schulc E. Demand for community-based Case Management in Austria - a qualitative analysis. BMC Nurs 2022; 21:5. [PMID: 34983497 PMCID: PMC8725559 DOI: 10.1186/s12912-021-00775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/24/2021] [Indexed: 12/03/2022] Open
Abstract
Background The number of people with complex nursing and care needs living in their own homes is increasing. The implementation of Case and Care Management has shown to have a positive effect on unmet care needs. Research on and implementation of Case and Care Management in the community setting in Austria is limited. This study aimed to understand the changes and challenges of changing care needs by mobile nurses and to evaluate the need for Case Management in mobile care organizations by investigating the evolution of mobile care nurses‘task profiles and the challenges in working in a dynamic field with changing target groups and complexifying care needs. Methods A qualitative study with reductive-interpretative data analysis consisting of semi-structured focus groups was conducted. Community care nurses, head nurses, and managers of community mobile care units as well as discharge managers of a community hospital (n = 24) participated in nine qualitative, semi-structured focus groups. The recorded focus groups were transcribed and analyzed using qualitative content analysis. Results The analysis revealed three main categories: the complexity of the case, innerinstitutional frameworks, and interinstitutional collaboration, which influence the perception of need for further development in the direction of Case and Care Management. Feelings of overwhelmedness among nurses were predominantly tied to cases that presented with issues beyond healthcare such as legal, financial, or social that necessitated communication and collaboration across multiple care providers. Conclusions Care institutions need to adapt to changing and increasingly complex care needs that necessitate cooperation between organizations within and across the health and social sectors. A key facilitator for care coordination and the adequate service provision for complex care needs are multidisciplinary institutional networks, which often remain informal, leaving nurses in the role of petitioner without equal footing. Embedding Case and Care Management in the community has the potential to fill this gap and facilitate flexible, timely, and coordinated care across multiple care providers. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-021-00775-0.
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Affiliation(s)
- Alessandra Schirin Gessl
- LMU Munich School of Management, Ludwig-Maximilians-Universität (LMU) München, Geschwister-Scholl-Platz 1, 80539, Munich, Germany
| | - Angela Flörl
- Division of Integrated Care, Institute of Nursing Science, Department of Nursing Science & Gerontology, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria.
| | - Eva Schulc
- Division of Integrated Care, Institute of Nursing Science, Department of Nursing Science & Gerontology, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
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32
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Reid N, Mason J, Kurdyak P, Nisenbaum R, de Oliveira C, Hwang S, Stergiopoulos V. Evaluating the Impact of a Critical Time Intervention Adaptation on Health Care Utilization among Homeless Adults with Mental Health Needs in a Large Urban Center. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:57-66. [PMID: 33611924 PMCID: PMC8811242 DOI: 10.1177/0706743721996114] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study evaluated the impact of a critical time intervention (CTI) adaptation on health care utilization outcomes among adults experiencing homelessness and mental health needs in a large urban center. METHODS Provincial population-based administrative data from Ontario, Canada, were used in a pre-post design for a cohort of 197 individuals who received the intervention between January 2013 and May 2014 and were matched to a cohort of adults experiencing homelessness who did not receive the intervention over the same time period. Changes in health care utilization outcomes in the year pre- and postintervention were evaluated using generalized estimating equations, and post hoc analyses evaluated differences between groups. RESULTS Pre-post analyses revealed statistically significant changes in health care utilization patterns among intervention recipients, including reduced inpatient service use and increased outpatient service use in the year following the intervention compared to the year prior. However, the matched cohort analysis found nonsignificant differences in health service use changes between a subgroup of intervention recipients and their matched counterparts. CONCLUSIONS An adapted CTI model was associated with changes in health care utilization among people experiencing homelessness and mental health needs. However, changes were not different from those observed in a matched cohort. Rigorous study designs with adequate samples are needed to examine the effectiveness of CTI and local adaptations in diverse health care contexts.
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Affiliation(s)
- Nadine Reid
- 7978Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Joyce Mason
- 7978Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Mental Health and Addictions Research Program, ICES, Toronto, Ontario, Canada
| | - Paul Kurdyak
- Mental Health and Addictions Research Program, ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, 10071St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Claire de Oliveira
- Mental Health and Addictions Research Program, ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Centre for Health Economics, Hull York Medical School, University of York, York, UK
| | - Stephen Hwang
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, 10071St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Populations and Public Health Research Program, ICES, Toronto, Ontario, Canada
| | - Vicky Stergiopoulos
- 7978Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, 10071St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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33
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Lachaud J, Mejia-Lancheros C, Durbin A, Nisenbaum R, Wang R, O'Campo P, Stergiopoulos V, Hwang SW. The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial. J Urban Health 2021; 98:505-515. [PMID: 34181180 PMCID: PMC8382791 DOI: 10.1007/s11524-021-00550-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/28/2022]
Abstract
We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. Each group was randomized into intervention (HF) and treatment as usual groups, and 567 (98.6%) consented to link their data to health administrative databases. HF participants received a monthly rent supplement of $600 (Canadian) and assertive community treatment (ACT) support or intensive care management (ICM) support based on need level. Treatment as usual (TAU) participants had access to social, housing, and health services generally available in the community. Outcomes included all-cause and mental health-specific hospitalization, number of days in hospital, and ED visit. We used GEE models to estimate ratio of rate ratios (RRR). The results showed HF with ACT had no significant effect on hospitalization rates among HN participants, but reduced the number of days in hospital (RRR = 0.32, 95% CI 0.16-0.63) and number of ED visits (RRR = 0.57, 95% CI 0.34-0.95). HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374.
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Affiliation(s)
- James Lachaud
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada.
| | - Cilia Mejia-Lancheros
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - Anna Durbin
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - Patricia O'Campo
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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34
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Miler JA, Carver H, Masterton W, Parkes T, Maden M, Jones L, Sumnall H. What treatment and services are effective for people who are homeless and use drugs? A systematic 'review of reviews'. PLoS One 2021; 16:e0254729. [PMID: 34260656 PMCID: PMC8279330 DOI: 10.1371/journal.pone.0254729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic 'review of reviews' to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion. METHODS AND FINDINGS We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed. CONCLUSIONS People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.
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Affiliation(s)
- Joanna Astrid Miler
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, Scotland
| | - Hannah Carver
- Faculty of Social Sciences, University of Stirling, Stirling, Scotland
| | - Wendy Masterton
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, Scotland
| | - Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, Scotland
| | - Michelle Maden
- Institute of Population Health Sciences, University of Liverpool, Liverpool, England
| | - Lisa Jones
- Public Health Institute, Liverpool John Moores University, Liverpool, England
| | - Harry Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, England
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Schreiter S, Speerforck S, Schomerus G, Gutwinski S. Homelessness: care for the most vulnerable - a narrative review of risk factors, health needs, stigma, and intervention strategies. Curr Opin Psychiatry 2021; 34:400-404. [PMID: 33993170 DOI: 10.1097/yco.0000000000000715] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW To summarize the most recent literature on risk factors of homelessness, mental, and somatic health needs, healthcare use, stigma as well as intervention strategies for people experiencing homelessness. RECENT FINDINGS Studies identified adverse life events as well as mental health problems like drug use or suicidality as significant predictors of becoming homeless. Prevalence rates of mental disorders, especially substance use disorders, psychotic disorders, and depression are high. Barriers of healthcare use are financial resources and insurance status as well as experiences of discrimination. Aspects of trust and safety as well as age and gender were identified of high importance in the design of interventions. Strategies of permanent supportive housing like Housing First have shown a stable positive effect on housing stability, but not mental health outcomes. Peer support, forms of intensive case management, and harm reduction strategies are the most promising approaches to address these further needs. SUMMARY Exploration into the relationship of homelessness and mental health as well as adequate intervention strategies is far from being conclusive. Especially, the development of effective interventions addressing issues of trauma, stigma and discrimination, community integration, and mental health needs is still in its infancy.
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Affiliation(s)
- Stefanie Schreiter
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, Berlin, Germany
| | - Sven Speerforck
- Universitätsklinikum Leipzig, Klinik und Poliklinik für Psychiatrie, Leipzig, Germany
| | - Georg Schomerus
- Universitätsklinikum Leipzig, Klinik und Poliklinik für Psychiatrie, Leipzig, Germany
| | - Stefan Gutwinski
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany
- Psychiatrische Universitätsklinik der Charité im St. Hedwig-Krankenhaus, Berlin, Germany
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Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness. J Gen Intern Med 2021; 36:1944-1950. [PMID: 33515192 PMCID: PMC8298720 DOI: 10.1007/s11606-020-06483-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. OBJECTIVE To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. DESIGN This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. PARTICIPANTS Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. MAIN MEASURES Unplanned all-cause readmission to the study hospital within 90 days of discharge. KEY RESULTS Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). CONCLUSION Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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Magwood O, Hanemaayer A, Saad A, Salvalaggio G, Bloch G, Moledina A, Pinto N, Ziha L, Geurguis M, Aliferis A, Kpade V, Arya N, Aubry T, Pottie K. Determinants of Implementation of a Clinical Practice Guideline for Homeless Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7938. [PMID: 33138054 PMCID: PMC7663114 DOI: 10.3390/ijerph17217938] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/21/2020] [Accepted: 10/26/2020] [Indexed: 12/19/2022]
Abstract
Clinical practice guidelines can improve the clinical and social care for marginalized populations, thereby improving health equity. The aim of this study is to identify determinants of guideline implementation from the perspective of patients and practitioner stakeholders for a homeless health guideline. We completed a mixed-method study to identify determinants of equitable implementation of homeless health guidelines, focusing on the Grading of Recommendations Assessment, Development and Evaluation Feasibility, Acceptability, Cost, and Equity Survey (GRADE-FACE) health equity implementation outcomes. The study included a survey and framework analysis. Eighty-eight stakeholders, including practitioners and 16 persons with lived experience of homelessness, participated in the study. Most participants favourably rated the drafted recommendations' priority status, feasibility, acceptability, cost, equity impact, and intent-to-implement. Qualitative analysis uncovered stakeholder concerns and perceptions regarding "fragmented services". Practitioners were reluctant to care for persons with lived experience of homelessness, suggesting that associated social stigma serves as a barrier for this population to access healthcare. Participants called for improved "training of practitioners" to increase knowledge of patient needs and preferences. We identified several knowledge translation strategies that may improve implementation of guidelines for marginalized populations. Such strategies should be considered by other guideline development groups who aim to improve health outcomes in the context of limited and fragmented resources, stigma, and need for advocacy.
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Affiliation(s)
- Olivia Magwood
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada; (A.H.); (A.S.); (L.Z.)
| | - Amanda Hanemaayer
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada; (A.H.); (A.S.); (L.Z.)
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Ammar Saad
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada; (A.H.); (A.S.); (L.Z.)
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Ginetta Salvalaggio
- Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
| | - Gary Bloch
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON M5C 2T2, Canada;
- Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Inner City Health Associates, Toronto, ON M5C 1K6, Canada
| | - Aliza Moledina
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
| | - Nicole Pinto
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Layla Ziha
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada; (A.H.); (A.S.); (L.Z.)
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Michael Geurguis
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada; (M.G.); (N.A.)
| | - Alexandra Aliferis
- Michael C. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Victoire Kpade
- Department of Medicine, McGill University, Montreal, QC H3A 0G4, Canada;
| | - Neil Arya
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada; (M.G.); (N.A.)
- Department of Family Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Tim Aubry
- School of Psychology & Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
| | - Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 6M1, Canada; (A.H.); (A.S.); (L.Z.)
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Ly TDA, Dao TL, Hoang VT, Braunstein D, Brouqui P, Lagier JC, Parola P, Gautret P. Pattern of infections in French and migrant homeless hospitalised at Marseille infectious disease units, France: A retrospective study, 2017-2018. Travel Med Infect Dis 2020; 36:101768. [PMID: 32504668 DOI: 10.1016/j.tmaid.2020.101768] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/25/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND No research has been conducted on the clinical characteristics and outcomes of homeless patients (HP) hospitalized in Infectious Disease Units (IDU). METHODS We conducted a retrospective survey among 98 HP and 98 non-HP admitted between 2017 and 2018 in several IDUs in Marseille, France. RESULTS HP were more likely to be migrant, to report frequent alcohol consumption or illicit drug use, and to present with respiratory symptoms at admission compared to controls. The most common final diagnoses in HP were respiratory tract infections (other than pulmonary tuberculosis [PTB], 35.7%), sexually transmitted infections (20.4%), cutaneous and mucosal infections (19.4%) and tuberculosis (12.2%). Sexually transmitted infections and ectoparasite infestations were significantly more frequent in HP compared to controls. One HP died from pleural effusion as a complication of PTB. The surviving HP had a longer length of stay (LOS, average 11.6 ± 13.6 days, p < 0.0001) than controls; independent factors of increased LOS were tobacco use (p = 0.009), tuberculosis infection (p < 0.0001), urinary tract infection (p = 0.018) and bacteraemia (p = 0.018). After hospital discharge, attendance at subsequent planned consultations was significantly lower in HP (0.72 ± 1.25 times/persons) compared to controls (2.03 ± 2.2). CONCLUSIONS We suggest that HP present specific demographic characteristics and patterns of infectious diseases compared to other patients and therefore require adapted management.
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Affiliation(s)
- Tran Duc Anh Ly
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; IHU-Méditerranée Infection, Marseille, France
| | - Thi Loi Dao
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; IHU-Méditerranée Infection, Marseille, France; Pneumology Department, Thai Binh University of Medicine and Pharmacy, Viet Nam
| | - Van Thuan Hoang
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; IHU-Méditerranée Infection, Marseille, France; Family Medicine Department, Thai Binh University of Medicine and Pharmacy, Viet Nam
| | - David Braunstein
- Department of Medical Information, APHM, Marseille, France; Aix-Marseille Univ, EA 3279 - Public Health, Chronic Diseases and Quality of Life - Research Unit, 13005, Marseille, France
| | - Philippe Brouqui
- IHU-Méditerranée Infection, Marseille, France; Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France
| | - Jean-Christophe Lagier
- IHU-Méditerranée Infection, Marseille, France; Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France
| | - Philippe Parola
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; IHU-Méditerranée Infection, Marseille, France
| | - Philippe Gautret
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; IHU-Méditerranée Infection, Marseille, France.
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Khan BM, Reid N, Brown R, Kozloff N, Stergiopoulos V. Engaging Adults Experiencing Homelessness in Recovery Education: A Qualitative Analysis of Individual and Program Level Enabling Factors. Front Psychiatry 2020; 11:779. [PMID: 32848944 PMCID: PMC7424067 DOI: 10.3389/fpsyt.2020.00779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/22/2020] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Recovery Education Centres (REC) in mental health offer a new model of providing recovery supports through emancipatory adult education and recovery-oriented service principles. Despite the widespread adoption of RECs, there is limited evidence regarding factors enabling engagement and participation, particularly for unique subpopulations or service delivery contexts. The Supporting Transitions and Recovery Learning Centre (STAR) in Toronto, Ontario is the first REC in Canada and one of few worldwide supporting adults transitioning out of homelessness. This research aimed to investigate individual and program level enablers of engagement and participation in a REC for this population. METHODS Qualitative methods were used to explore the experiences of 20 service user participants through semi-structured interviews exploring their experiences of REC participation and perceived key program features. Interviews were conducted between July 2017 and June 2018, six to 14 months following REC enrollment, and analyzed using inductive thematic analysis. RESULTS In contrast to past experiences with health and social services, participants described a welcoming and respectful physical and interpersonal environment with low-barrier seamless access facilitating their engagement and participation. Although the realities of homelessness presented barriers for some, participants described that the involvement of peers, as role models, and the self-directed, strengths, and skills-based curriculum, co-produced and co-delivered by peers and professionals, were instrumental in activating the process of recovery through education. CONCLUSIONS/IMPLICATIONS Findings are consistent with the growing evidence base of the defining features of RECs and suggest this model can be successfully extended to support recovery among adults transitioning out of homelessness. This unique examination of Canada's first REC for adults exiting homelessness can help guide program and policy development to better support this disadvantaged population.
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Affiliation(s)
- Bushra M Khan
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nadine Reid
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rebecca Brown
- Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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